She Passed the Hand-Drop Test


I was in a bad mood one afternoon when we were called for a 35 year-old-female with chest pain.   As we pulled up behind the fire truck in front of her high-rise apartment building, I thought that it was silly to send six people on a call like this.  I thought for a second about whether or not we should bring the airway bag in, but grabbed it at the last second.  We were escorted to the elevator by a security guard, went up to the tenth floor, and down the hallway towards an open door.  We walked in to the nicely furnished apartment to find a young woman seated on a couch, whose skin was pinker than mine, slumped back with her mouth wide open, and she took a gasp.

This is bullshit, I thought.  She opened the door for us, pretended to collapse, and is holding her breath.  When she did not respond to someone speaking to her, I did the unvalidated and useless “hand drop test” to see how unconscious she really was.  I held her had up, and she smacked herself in the face.  She also did not gasp again in the few seconds we had been with her.  So we moved her to the floor, and discovered that her arms, legs, and neck were flaccid.

She had no pulse, and the firefighters started CPR.  She was in a course V-fib on the monitor, and we shocked her with the defibrillator.  My partner intubated her during compressions while I started an IV.  The firefighters did a great job rotating compressors, and it was a textbook pit crew.  She got a pulse back after a few shocks and started breathing occasionally, and her 12-lead showed a huge inferior-wall MI.  Her blood pressure stayed below below 80, and we hung amiodarone and dopamine drips on the way to the hospital with a cath lab.  She ended up having a 100% RCA occlusion that was stented, and she was discharged with no neurologic deficits a few days later.  And I thought she was faking.

I’m not proud of this story.  Had the outcome been different, I’m not sure I would have the courage to share it.  It happened at a time when I had become complacent and stopped learning.  She did not fit the pattern of any truly sick patients I had seen before, and perfectly fit one of malingering patients that I had.

Thinking back, the open door was what made me think she was faking the most.  After all, no one opens the door between calling 911 and collapsing.  But she did, and it saved her life.  Otherwise we would have knocked on the door for some time and asking the dispatcher to call her back.   We may or may not have heard a phone ring inside.  Then we would have confirmed the right address and apartment number.  Then we would have decided whether or not to force entry.  If we decided to do that, we would have had building maintenance come or go back to the truck for a Halligan bar.  I would have believed she was sick after gaining entry, but by then it would have been too late.

Next was her skin color.  Most cardiac arrest patients appear cyanotic.  Even the few patients whose arrest I witnessed appeared pale and diaphoretic beforehand.  Her apartment was nicely furnished and a mountain bike hung from the ceiling.  There was no medical equipment, ash tray, empty liquor bottles, pills, or drug parapherenalia which are consistent with young cardiac or respiratory arrest patients I had encountered up to that point.  All of that lead me to do the pointless Hand Drop Test.  Peter Canning and Rogue Medic describe better than I can why that is.

We rely on pattern recognition to quickly process complicated situations, such as differentiating COPD from pulmonary edema.  But it does not work the other way around.  That’s called complacency, and fortunately this young woman survived mine.

Comments

  1. Nice story Bob, thanks for sharing. The scary thing is that we have all had our share of these, and some of them didn’t turn out so good as yours. We had a 31 year old female with similar cardiac pathology, luckily we caught her.
    Interesting about your patients colour, you must have turned up pretty quick after she arrested, that’s all I can think of..

    • emspatientperspective says:

      Thanks Sonja. We arrived at her side within 10 minutes of her 911 call, so I suspect she did arrest very shortly before.

  2. emspatientperspective says:

    Thanks again Greg!

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  1. […] At the EMS Patient Perspective Bob Sullivan reminds us to park our complacency and constantly be mindful that any call can be or become a life threatening emergency. Please read, share, and comment on She Passed the Hand-Drop Test. […]

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