Joseph F. Clark, Ph.D.

Because it was a home game, we had a fairly standard procedure for such things; I called the head trainer and briefed him. It was decided that I was taking her to the hospital for x-rays and the emergency physician would call the team physician for orders after the injury had been assessed. Meanwhile the team physician called the emergency room to tell them we were coming in. Casey did not want any family or friends called until more was known about the injury.
The emergency room was completely empty when we arrived. From my days on the ambulance I recognized the expressions on the faces of the ER staff, who were mildly glad to have some business, but still cautious in their joy because a first patient can be quickly followed by many. I didn’t know any of the ER nurses, but gave them a report on my patient as I would have if she were an ambulance patient. Before I knew it, I heard myself saying, “ Nineteen-year-old female with a witnessed traumatic event to the medial aspect of the right knee approximately 1.5 hrs ago. No prior dizziness, no LOC, no KON, vitals stable and good throughout. Patient was iced immediately and treated with I.C.E. Exam shows instability of the medial collaterals, guarding and localized pain.” They knew that LOC meant loss of consciousness, KON meant knock on noggin and I.C.E. meant ice, compression and elevation for treating the injury. Casey looked at me with a mixture of confusion and fear.
The nurse tending to Casey asked me, ‘‘Are you the boyfriend?’’
‘‘No, I’m the student trainer for the team. I tended to her injury in the acute phase.’’
She nodded and went on, paying no attention to what I had said. While it annoyed me that they were not using the info I provided, I understood it. In the emergency care situation, bystanders and helpful friends were not reliable witnesses and often would embellish the truth. To the ER staff I was not “on the job,” so my information could not be trusted. I needed to form a relationship with them to build trust. That was not going to happen today, but it was going to start today.
The ER visit went fairly predictably from my perspective, so I spent a lot of my time keeping Casey apprised of what was happening and translating the ER jargon for her. I even explained my mini report to the ED staff to her. She kept asking me what had happened and what was wrong with her leg, and I had to tell her, “I am not a doctor, so I cannot do a diagnosis.”
“OK, so what do you think MIGHT have happened when I twisted my knee?” she said sarcastically.
“Casey, I think you MIGHT have torn some ligaments in your knee,” I said.
She looked at me and got very flushed in the face. Tears started to well up in her eyes and she stared at her knee angrily as if it had done some terrible wrong to her.
“I’ll probably lose my ride,” she said, referring to her basketball scholarship.
Right now, more than anything in the world, I wanted to help Casey, but I couldn’t. Not until the x-rays were back and a diagnosis made. Once we trainers had a diagnosis, we could start on treatment and rehab. Even if the diagnosis meant surgery, we could do lots of pre-surgery conditioning to help speed her recovery afterward. If an athlete is scheduled for surgery, the advice we usually give is to NOT take it easy. Strengthen that limb and work that joint as much as the surgeon will let you. Often the surgeons will say, “Do what you want—if you injure it more, I can fix it when I’m in there.” While this statement may seem a bit cavalier, it is somewhat true. If a ligament is torn in half, exercise will not tear it more. But all of these things needed to wait for the diagnosis. For now, my job was to keep Casey entertained and make sure that when we got her marching orders they were followed, which they would be.
The x-rays came back with no bone damage. The team physician would see Casey first thing tomorrow morning. Casey was prescribed some mild painkillers and RICE (rest-ice-compression-elevate) treatment for tonight. Tomorrow we would be doing a more complete exam. Although I was not scheduled to work tomorrow, I would be there because Casey was on my team. Even though I couldn’t play with them on the court, I felt like I was a member of the team and she was part of my responsibility as a teammate.
The head trainer, Scott Patt, and the team physician, Charles Bowen, did the exam on Casey. She no longer had any obvious ligament supporting the inside of her knee. This was clear because her right knee could be bent out to the right with very little pain or resistance on her part. I had done this same test last night, but not to the extent that Dr. Bowen now did, making her knee look like it had a hinge enabling it to move from side to side like a pendulum. Her ACL was then tested by seeing if the knee would slide forward or backwards. This was done by having Casey sit on the training room table with her feet on the table and the knee bent about 45 degrees. Dr. Bowen then pushed and pulled on Casey’s knee. It slid back and forth by what seemed like inches, making her knee joint look like a dresser drawer being pulled out and pushed back in again. This was all indicating that the ACL was damaged, but maybe not as severely as the MCL. Finally, to see if Casey had the terrible triad, Dr. Bowen palpated the inside of Casey’s right knee while moving it in different directions. He soon declared that the cartilage in the medial meniscus was damaged too. The medial meniscus is a large piece of cartilage that acts as a buffer between the femur or thighbone and the tibia or shinbone. The medial meniscus is also attached to the MCL, so the two are often injured together. Casey indeed had the terrible triad and would need surgery. Casey only wanted to know WHEN she would be able to play. Shaking his head, Dr. Bowen said not this season.
Casey was inconsolable. Her parents came to pick her up from the university later that day to get a second and third opinion. All the opinions were the same. She had the triad and needed surgery. I promised Casey I would work with her to get ready for the surgery and help her rehab the knee for next season. She decided to take the rest of the term off, so I could not work with her on rehab. She assured me she would do some “stuff” at home. Her surgery was not very successful and she did not return to the university. Casey lost her ride. Despite my best intentions and all of my efforts to be encouraging, I could not help Casey.
I missed Casey and so did the team. We still had a great season, only losing 7 games out of 30. I had a few more trips to the ER during the season, but fortunately nothing as serious as Casey. I did, however, build a rapport with the ER staff and they began to trust my clinical reports. They would report my vitals in their charts, which was a big vote of confidence on their part.

Chapter 1. My Career as an Athletic Trainer.

As a child I always wanted to be a medical professional when I grew up. Some of my earliest memories are of being fascinated by biology and medicine. I wanted to be Einstein or a physician. I took my first first-aid course at the age of 13 in a class full of adults and was their equal in the book work and practical work. I was an expert on bandaging and splinting. My mother tells me that when I was 11 my Christmas wish list contained two things; Legos™ and medical books. I was trained as an emergency medical technician by the time I was 18, and fantasized about being a paramedic, athletic trainer, researcher or physician. While I bounced around between career choices, I had a general sense of where I was going.
I wanted to get an advanced degree to increase my chances of “helping people” someday. I had decided upon that general direction but was not too sure what discipline to choose. So during my first four years of college I needed to start making choices and decisions as to what type of graduate degree to pursue. That is true for all college students; there are many choices regarding graduate school that need to be made as an undergraduate. So in effect everyone’s graduate education starts as an undergraduate.
I kind of fell into the world of athletic training when I went to college. The university knew I was an experienced ambulance person and they needed that skill set in the training room.
Athletic training is a para-profession that combines sports medicine, exercise, fitness and athletic competition. Athletic trainers are highly trained paraprofessionals who must manage injuries and help athletes improve their performance. Thus a breadth and depth of theoretical and applied knowledge is needed to be effective. I had worked on ambulances to help pay my way through college, was interested in medicine and science, and had an interest in helping people, so becoming an athletic trainer seemed like a logical extension of these interests. It seemed that a great way to help people would be to work with people who wanted to be helped, wanted to improve themselves, and were looking for help from people like me. Working with athletes to help them stay healthy, recover after injury, and to improve their performance seemed ideal. The athletes appreciated the help and the athletic trainers I worked with were smart people who also wanted to “help people.”
I easily got a job as a student athletic trainer and took some classes in athletic training as a complement to my Chemistry major and Biology minor. A student athletic trainer assisted the university’s full-time athletic trainer and got a stipend. I already knew a lot about anatomy and physiology, so the training classes were relatively easy. Learning how to tape an ankle was pretty easy for me, too, because it was so much like bandaging. When I worked on the ambulance I could bandage anything and do it fast to stop the most serious bleeding, so now I was taping an ankle to keep it from twisting during play. I was indeed helping people. These people just wanted to play a game as opposed to many of the people I tended to on the ambulance, who wanted to drive recklessly, do drugs or engage in bar fights. The career change for me was not away from helping people but towards helping a different kind of person: the competitive athlete.
Athletic trainers got know most of the athletes we worked with very well, and fortunately we rarely if ever had to deal with life-threatening injuries or death. Serious injuries could end a sports career or end a season, but it was mercifully rare to find an athletic trainer having to deal with a cardiac arrest.
Don’t get me wrong, however, athletes can sometimes die of heat stroke or have undiagnosed congenital heart disease that can cause sudden death. Then you would find the athletic trainer doing CPR and every single Certified Athletic Trainer must be trained in CPR and have regular re-certification. I often would be asked to instruct the athletic trainers in CPR because I was one of the few people to have actually done it – a lot. But that was when I was working on the ambulance, which was a life I did not want to go back to. I never wanted to be thumping on someone’s chest again, but was glad to impart knowledge and experience to those who might need to do CPR someday.
The skills needed for an athletic trainer are actually quite similar to those of an ambulance person. You need to be well trained, ready for anything, and calm under pressure. An ambulance person might be under pressure because a couple of family members are watching as you try to help a loved one during some emergency. There is the pressure from the medical emergency itself plus the pressure of the family members watching the events unfold. An athletic trainer, likewise, might be called upon to tend to an injured athlete during a major sporting event in front of thousands of people. Some of my athletic trainer colleagues have been on the field during nationally televised games, which means millions of people watching. So, calmness under pressure is an especially good thing for the athletic trainer.
Within a few weeks of joining the athletic training staff I was put in charge of the woman’s basketball team. I had a student trainer supervisor and the full-time trainer to use as resources when needed. I quickly learned the injuries that female basketball players were likely to get and learned how to help with stretching, warm up, and rehab. For athletic trainers a substantial part of the job is preventative taping for joint support. Taping ankles is what many people think of when the subject of supportive taping is discussed, but an adept athletic trainer can tape many joints to give a little extra support. With a good knowledge of anatomy and tons of experience in bandaging all sorts of limbs, I quickly mastered the art of supportive taping of all the major joints prone to injury in the female basketball player.
The woman’s basketball team was a lot of fun and they were consummate competitors. The women also were very conscious of their performance and their physical characteristics. They constantly wanted to improve their game and themselves. So, if I gave them recommendations to do some stretching exercises or strength training advice, they took it. Often they would do more than required to be better. While this was not always the best thing to do, it showed that they were listening and wanted to be helped. What a joy it was to work with these people, and I got to go to all the games and sit on the team bench, which is the best place from which to see a game.
Every once in a while a serious injury would occur. In my first season as the women’s basketball trainer, the lead point guard, the star of the team at the time, injured her knee during a game. I ran onto the court to tend to her. She described a twisting sensation in her right knee followed by a popping sound or unstable sensation on the inside of the knee. She suddenly felt intense pain and at the same time the knee felt “all loose,” she said. That is a fairly typical description of a tear in the knee ligaments (likely the medial collateral ligament or MCL), the cartilage, or the anterior cruciate ligament (ACL). It could be all three at the same time as well, a combination injury known as ”the terrible triad,” which could be a career-ending injury.
The woman’s name was Casey and she was a criminal justice major. The basketball scholarship she had was her way of getting an education to become a state trooper and eventually a detective. Right now, Casey was not thinking about her scholarship; she was thinking about the pain in her knee and whether she could play the rest of the game. Without doing an exam, I knew that she was not playing again tonight and her future was in doubt. I did a quick evaluation on the court, and much of what I was doing was trying to calm her down and get her to focus on me rather than her quickly swelling knee. With help from the assistant coach, I got her to the end of the bench where the injured players and myself would sit. I put some ice on her knee and told her to rest it a bit for now and we would do more of an exam at half time. As the adrenaline that had kept her pumped on the court started to subside, the tears started to flow. She was upset about the injury and concerned about the ramifications of it all.
At half time she said it didn’t hurt much anymore and she really wanted to try to get back into play. I unwrapped the bandages holding the ice bags in place and examined the knee again. There was a substantial amount of swelling on the inside of her knee. I did not try to evaluate for tenderness, but I did want to see how stable the knee was. To test her knee’s stability I had her get on the training room table and asked her to sit back and relax. I picked up her uninjured leg and to show her what I was going to do, I put one hand under her ankle and held up her leg. With her good leg straight, I gently pushed on the outside of the knee and she just looked at me. I told her that pushing like that should not hurt and that the knee should not move. I went then to her injured leg and gently picked it up by cradling the ankle. She would not let the knee straighten but showed no sign of pain. I asked her if it hurt to straighten it, and she said it just felt better this way. With the knee slightly bent, I again very gently pushed from the outside in, looking for any sign of pain. She did not wince at all. But she did look very surprised because her knee now bent sideways in a way it was not supposed to. I had hardly pushed it at all, and I had the information I needed. She had a serious knee injury and was not going to be playing for a while. There were other tests I could do, but they were not needed now. I told her that she was not playing again and put the ice back on her knee.

To be continued.

The first half of Chapter 1 of My Graduate Education will be posted Friday Aug 6 with the conclusion of Chapter 1 posted on Aug 9. Lots more to come.

Introduction to My Graduate Education:
Why is “helping people” in quotes?

“Helping people” is a cliché. People entering caring professions to “help people” are sadly too often not helpful or do not deal well with people. This is especially true when one is trying to help people who do not want to be helped. I have interviewed doctoral students, medical students, undergraduates and MD/Ph.D. students for many years and the concept of “helping people” always comes up in these interviews. But the sincerity behind it sometimes seems questionable. “Helping people” can be done in many ways, like being courteous on the highway, or checking on a sick neighbor. I’ve seen a roomful of people watch motionlessly as a colleague who dropped a bundle of papers scurried around to pick them up – unaided. No one (sadly, myself included) helped that person. This occurred in a hospital seminar room full of alleged “caring professionals.”
That incident, along with comments from emergency room and intensive care unit personnel such as, “that person is too stupid to live,” or “I look forward to reading the obituary of that low life,” made me realize that a lot of us have forgotten why we entered a caring profession. Obviously, such comments are water cooler conversations, and only come when a patient has shown a blatant disregard for his or her own life or the lives of others, but it is a symptom of the sad cynicism that takes hold sometimes. This is the reason for the quotation marks around most references to “helping people” in my books. It is still what I and other paramedical professionals try to do, but it is in quotes to remind us that it should not be an abstract concept. “Helping people” is not just a job; it is a lifestyle.

Stay tuned for chapter 1 of My Graduate Education; My Career as an Athletic Trainer.

I have been asked multiple times what happened to some of the people I talked about in “My Ambulance Education”. Holly, Bill, My brother, and others are real people and their stories are equally interesting and important. They shaped my life and in many ways, continue to do so. There is a metaphor of two ships passing in the night to characterize how people’s lives can intersect. To continue in that analogy, there are people whose passing left many ripples for me to ride on. So while some of the characters in “My Ambulance Education” have moved on to other ports, I can clearly say their passing through my life has changed my boat ride.

 For anyone who wants to know what it is like to write a memoir it is easy to give a brief philosophy that partially addresses that question. That is if you do not get yourself emotionally involved and in tears, you are not honest enough with what you are writing.

 What brings people to read about tragedy is because it is like watching or looking at a car accident and not being able to look away. It is emotional and we want to see it. We are drawn to our emotions by our emotions.

The link between writing a memoir and bringing back those emotions is a lot like that car accident we want to gawk at. If you have not brought back your personal car accident back to life in the writing it won’t be emotive enough for anyone else to want to gawk at.

Through My Ambulance Education I have been able to touch base with several of my friends and colleagues from those days in the early 1980s. Yes, that is nearly 30 years ago, and I can clearly say that they are as valuable to me now as they were then. Obviously the value of our relationships have changed, but there is value in having common backgrounds to draw upon and discuss.

I’m not sure if I’ve become the person they thought of me as back then, but I’m happy with where I am and that I’m not done yet.

I will be able to continue the saga concerning some of these people later in August. So please watch this space for more to come.

July 2010 showed a 25% increase in traffic to this blog. Thanks for visiting.

Let me give you some bits of information. The blog is now connected to 3 RSS and companion blog feeds.

I plan on starting two blog series: one in August concerning “My Graduate Education” and one a brief teaching series that should start in October. Which means I do think about and plan my blogs and will continue to post about twice a week, so please continue to keep checking and feel free to share with your friends or companion feeds.

I recently had the dubious distinction to participate in and serve on an national institutes of health grant review called an NIH study section. I’ve done this before and have reviewed lots of grants over the years, but there have been a lot of changes recently and it is a whole new experience that is still very hard to swallow.

For those of you not familiar with the NIH peer review system, don’t tune out. Let me explain it as only a truly entrenched academic geek such as myself can.

First let me say that the US government’s NIH granting and reviewing system strives to be fair and transparent. But human peculiarities do indeed come into play as do politics and a little bit of luck. Did I mention semantics, bureaucracy, administration, economy, public perception and salesmanship are involved too? They are.

Let me begin with some facts. The NIH peer review is a system where experts in a given field read and review grant proposals that have been written and submitted by experts in the field.

A grant proposal typically has a research section, budget, resources and personnel sections. The length of the sections varies according to the type of grant proposal, but can be 100 pages long.

The study section can review large numbers of grants sometimes over 100. my study section reviewed about 25 in one day.

Each grant is assigned to 3 or 4 reviewers. I received 6 grants to review or about ¼ the total. The reviewers are expected to read these grants thoroughly cover to cover. I read mine 2 or 3 times. Prior to the meeting, 1 week, all grants are given numerical scores by the referees.

The reviewers are expected to also read all the grants in a study section. Let me tell you this takes an incredible amount of time and makes for one bleary eyed group of referees at these study sections. It is a lot of work and everyone takes it very seriously.

More facts about the review. There is a chair for the meeting and a couple of support personnel. The lead support person, called the grants management specialist (GMS) is a highly trained scientist and administrator. The chair is a respected and experienced scientist who defers to the GMS concerning procedures and admin issues. The chair also has substitute chairs in the case of there being a conflict or if the grant the chair reviewed is being discussed. Conflicts are most often a grant comes from that person’s institution. So I am not allowed to review grants coming from Cincinnati.

I apologize for this reading like a text book. Lets get to some interesting human dynamics. The primary referee as labeled by the GMS summarizes the science of the grant and gives an impression of the strengths and weaknesses. The other referees then add or reinforce details. These are supposed to be objective and dispassionate bits of information. It is so easy, however, to tell if a person is pushing for or against a grant. Plus the referees are quick to try to convince the others how smart they are. I had to suppress a chuckle on multiple occasions because of inane posturing by people.

Here are some excerpts I thought I would share. Note, I am redacting details to protect the people as well as the grants being discussed.

“I am likely the only person in the room capable of reviewing this grant.”

“In my study section we do it {this way}.” With the implication being others are wrong.

“it is a fatal error to call a neonatal rodent a model for pre-natal humans. These are my patients and they are not rodents.” This was silly because an MD seemed to want to dismiss all animal models here.

“It is simply wrong for them to call these {xyx} cells.” The response: “The applicant calls them {xyx} – like cells.”

“in my lab we do these experiments and we do it this way.” Again an example of different is wrong.

“This would be a great application if they studied {ABC}.” {ABC} is what the referee studies. The implication is that they do important research and the application does not.

Here is a quote from my notebook. “Shouting and karate chopping the desk does not make you right.”

What gave me tremendous concern however is the catch 22 that exists. There needs to be innovation in a grant but innovation often means little evidence from others. If you do new stuff, that by definition means others have not done it. Without evidence from others there is concern re performance ability and that leads to difficulty funding. So why be innovative? Do what others have done; others tend to be the experts making decisions anyway.

On another review that was highly innovative and the type of study that would make the national news if it succeeded, a particular person, who tended to karate chop to make a point, complained that the research group did not control for environmental variables. I had read the study as did the person making the complaint and I said that I thought they controlled for those variables by using geographic restrictions. The reviewer obviously missed that point and instead of admitting that this is a control mechanism, this colleague dismissed my point and the grant by saying that is not how everyone else, their lab, does it.

That is just sad.

This grant was novel, innovative and would have a huge impact. But because a big ego, attached to a loud voice, dismissed it due to their own missing facts the grant sank in the scoring and may never be done.

On that sad note, I’ll end with one more fact. There were about 25 grants reviewed that day and I think 7 or 8 should have been funded, but there were only sufficient funds to fund 3.

Dear EMS practitioners,
I apologize in advance if some of this is indelicate, but it is one person’s opinion and is intended to advance the profession.
Yours truly,
Joe Clark

Prehospital care is medical treatment and care that is given by ambulance personnel, often in an ambulance. EMTs and paramedics provide a wide range services to the acutely injured patient. Often this care occurs in the very acute phase of an injury or disease when time is critical.

I think most people consider ambulance personnel as valued members of society and the medical care paradigm. These people are professionals. There is one group of people who, I think, do not consider EMTs and paramedics as medical professionals and that group is the EMTs and paramedics themselves.

This is a contentious statement but intended with the utmost of respect. I think that ambulance personnel are to a certain extent self deprecating and poor at self promotion such that they are selling themselves short. When I worked on the ambulance I aligned myself with the police and fire personnel on the streets and felt I was handing off the patient to another world, the white collar world in the hospital. The hospital personnel could never appreciate what happened on scene, but the police and fire personnel did because we were often there together.

When I hear my professional colleagues talk about, “wild times” in the emergency room, I smile discreetly and say nothing as I recall out of control scenes of violent fights with more victims than EMTs and the cops not yet there to help, while in the emergency room, there were lots of people and security backup. I relate to the police, fire and ambulance.

The ambulance personnel are without question medically trained and qualified despite often being pigeonholed as field personnel. A paramedic can have 1000 to 3000 hours of training (depending upon regional differences) and will often be able to give his or her full attention to one patient at a time for extended periods during transport. This is a unique setting where quality care and advanced care can be given. But, did you know that ambulance personnel are not allowed to “diagnose?”

I think it is sad. Truthfully it is silly semantics, but it does diminish the ability of ambulance personnel to perform their job.

I know and understand that paramedics and EMTs do not have X-ray machines or MRIs, but they do have eyes and ears. So they can see if an arm has a bunch of muscle and blood protruding from the skin, they should be able to say or diagnose a laceration and treat it. I would go farther than that. I believe that EMTs and paramedics should be able to treat and release.

There I said it. We need EMS practitioners.

Say for example, a farmer has a laceration that needs to be cleaned and bandaged. The ambulance personnel should be able to make a “house call” and bandage that arm so that the farmer can finish his/her chores. The patient could follow up with a physician for antibiotics or further treatment if needed. But now, the farmer will hesitate to call the ambulance because it means that they are committed to an ambulance ride and time lost in the hospital. So they get no care or very delayed care leading to increased morbidity when trained medical personnel are only a phone call away.

I fully support and recommend an educational component to EMT and paramedic training similar to a nurse practitioner’s degree where they can provide stand alone care to some patients. They can bill for said services and refer patients to physicians as needed. This will help decrease transport of walking wounded to overflowing emergency rooms and provide care to people who might otherwise not seek it.

Finally, and importantly, it is about time that EMTs and paramedics who seem to have a blue collar persona be empowered to be the medical practitioners they deserve to be. An EMT-practitioner or paramedic-practitioner designation will go a long way to up the ante for ambulance personnel.

Ever wonder where the term “catty” came from. It came from cats.

A friend has three cats. Two males and one female. The female named Libby is petite and precocious. One of the males, named Winston, is the senior cat in the house with the middle male, Clovis, having been adopted as a playmate for Winston. All the kitties have been spay or neutered.

Winston and Clovis are best friends and both very calm gentle giants and bed buddies for their “mom.” Because Clovis was gaining weight and becoming less active at only 2 years old, his mom decided Libby, his younger sister from the same litter, might be a good addition to add more activity to everyone’s life.

Libby was a welcome addition to the house. Clovis seemed to remember his sibling and Winston loves everyone. Libby played and integrated well behaving like a kitten pouncing and playing with everyone. With Libby’s gregarious personality she quickly became the alpha female and head of the house. Often, she would ambush a sleeping Clovis or Winston. The much larger males continue to live up to their gentle giant status never being rough with little Libby.

Winston and Clovis closed ranks and would sleep together in solidarity and defend each other from random pounce attacks by the playful Libby. Libby, as the alpha feline, would steal food from the boys and make her dominance known at every opportunity and the boys went along with the new house dynamics.

As the weather turned from Winter, to Spring and finally the hazy lazy days of Summer the kitties were given more and more opportunity to go outside on the deck of the third floor apartment. Libby quickly figured out how to go from one deck to another and escaped, but turned up at the front door a few days later. Possibly through a neighbor’s apartment. Clovis and Winston made less frequent forays to neighboring decks and stayed close to home. Mom had to do a head count before closing the sliding glass door to prevent losing a kitty.

On one occasion Mom accidentally closed Clovis outside with Winston and Libby inside. Winston loudly announced and alerted to the deck door so that Mom finally figured that someone was missing. Outside was little Clovis happy to come back in. Obviously that made Mom very happy that Winston “told” her that one of the babies had been left outside, but it also made her try to recall if a similar alert was made when Libby was outside.

Not recalling an alert from Winston or Clovis when Libby was left outside, Mom decided to do a little experiment. Libby was “accidentally” left outside and Mom watched the behavior of Clovis and Winston. The boys said nothing. She made sure that they knew Libby was outside and they acted like nothing was wrong. The boys had obviously formed an alliance and were keeping their little secret.

When mom let Libby in, Libby seemed to actively admonish the boys with vigorous swats and pounces as if to say, “you left me out there on purpose.” Libby is still boss, but the boys seem to know how to hang together.

I wanted to express an opinion to my EMS colleagues. This is not a policy statement or educational mandate, but simply one person’s opinion and an invitation to think about some types of brain pathology seen in the pre-hospital setting. Please recall that my career is concerning the diagnosis, treatment and work towards improving the outcomes of patients with stroke and traumatic brain injury. While I assure you there are new technologies coming to help diagnose these patients they are not ready yet.

Stroke and brain injured patients often are confused, agitated, “frontal” and / or sleepy. What becomes problematic is the patient who communicates apparently cogently but who may not be able to make appropriate decisions or refuse medical aid. The brain can compartmentalize functions fairly well sometimes and good verbal skills can mask severe pathology elsewhere in the brain.

Here is a scenario to consider. You have a possible stroke patient; the patient is hemiplegic, agitated and combative. While the more common scenario is a sleepy somnolent stroke patient this presentation is quite possible. If the patient is hemiplegic do they acknowledge the weakness on one side? There is the phenomenon of the alien hand where patients do not recognize their own plegic extremities. You can hold a person’s hand in front of their face and ask them, “whose hand is this?” and they will say yours or I don’t know. If this patient is trying to refuse medical aid, it may be in their best medical interest to transport them nonetheless. The patient has a real and potentially serious brain condition and needs urgent care. How you facilitate those next steps is a subject for medical control and agency policy. Options are to sedate and transport the patient because they are confused, agitated and a medical emergency because brain cells are dying. Communicate with medical control or the hospital and get a confirmation of your suspicions. Work harder to convince the patient to be transported. Or you could leave the patient where they are.

While alien hand is an extreme example, the difficulty comes in trying to assess when denial is part of a brain’s pathology. Please remember that there is NO consensus on procedures, but I would like to offer a suggestion for the EMS community. If you see a patient with two previously undiagnosed neurologic abnormalities along with denial, that patient may be unable to make appropriate decisions as to their medical care. For example, weakness and confusion in a suspected stroke patient is consistent with many kinds of stroke. The confused patient found at home may want to stay home in their comfort zone but that may not be in the best interest of the patient. Even if they can clearly state that they want to stay home and are fine, that denial may be an added symptom to the weakness and confusion process of a stroke patient. Do they acknowledge the problems they have and have a strategy for dealing with them?

Here is a brief list of physical symptoms that might be considered as neurologic in such situations: numbness, tingling, tremor, asymmetry (including facial expressions, pupils and strength), incontinence, diaphoresis, altered speech, disorientation, confusion, and fever.

So a patient sitting at home in their comfy chair stops talking to their family. The family calls 911 and you find the patient still in their chair, talking but not using their left arm and has a new facial twitch. The family confirms the patient is just not right and the above observations are new. However, the patient can clearly tell you they are fine, they know where they are and the minor inconveniences of being unable to use their left arm is no problem; denial. Even if they adamantly refuse transport, this person may be in the middle of a serious stroke.

The key to consider is that there are two interpretations here. One, is transporting a patient “against” their stated wishes, when you have a clinical impression that that person’s brain is not functioning correctly. Transporting may cause consternation but normally little harm when done correctly. The alternative is leaving a patient in the process of clinically deteriorating. While they may recover they could also have a devastating cognitive outcome as the brain is in the process of a managing a severe pathology. Some lawyers might start to call this abandonment.

I have had the personal experience of sitting with a bunch of armchair quarterbacks reviewing a situation where a stroke patient says that their “problem” will get better. Said patient was able to refuse care and caregivers complied with that refusal. By the time the seriousness of the stroke was realized the brain damage was permanent. It is all too common to see a suspected stroke patient in relatively little distress with numbness and or weakness on one side of their body say things will be fine; AND people believe them. They are believable because they calmly say, “I’m fine, and do not want to go to the hospital.” The armchair quarterbacks will counter; if you suddenly lost feeling in your arm would you think that fine? Not likely.

As with any call, document clearly what is seen. Have a great relationship with medical control so that they can be ready to back you should you decide that the patient in front of you is not capable of making a decision concerning transport at this time. This may have to occur even when the words the patient says could sound clear and cogent, if the patient denies or does not recognize other clinical manifestations of their brain disorder the denial is likely to be masking something serious happening in the brain.

To avoid confusion, I do not think that any of the above is assessing “competency” of a patient. I think this is more discussing risk of a brain type disorder that needs medical evaluation. Before you go out into the field again ask yourself one question; “What is your agency’s policy on this subject?”