The Medical History is the Keystone

We all have been taught, and know to be true, that the history is the most important part of examining a patient. It’s usually questions that are like the stick hitting a piñata that allows the diagnosis to come out. Ask the right questions in the right way, and you figure it out. However, I find this is difficult to accomplish at times.

It’s easy when a guy says he punched a wall. The mechanism is apparent. No real trick here. He punched a wall.

It’s a completely different story when EMS brings in a guy because he hit a horse on a motorcycle. Now, on face value, this sounds interesting. “That’s a first” is an appropriate initial thought but, How does the history help? or does it distract? How can I get fooled?

It’s usually a preconceived notion.

A preconceived notion is when we make up our minds too early. It’s called a heuristic. We take mental shortcuts that can make us more efficient, yet they can get us burned as well. I did that twice this last shift, asking, “Is this your mom?” (No…it was a similar aged roommate!) Or, asking, “Are you her father?” Another wrong assumption that had me pulling my foot from my mouth. But my mind can be much more sinister and these quick judgments can have greater consequence than just creating an awkward social situation. I could label a guy a “drug seeker” and not treat his back pain correctly. I can decide that this “frequent flyer” is here from the same old thing when it actually turns out to be something new. This is how catastrophic mistakes can happen.

There can also be something magnified. It’s like when you see a mass on a CXR – and get pigeonholed looking at it, just to miss the pneumothorax. It’s the guy who comes in with a painful, non-life threatening fracture (clavicle) that distracts you from evaluating the c-spine.

We need to stay constantly vigilant and sharp. It’s the history that makes the magic happen for your diagnosis.

Now, if I told you that the horse died from the collision with the motorcycle; does that change your perception? It did mine. I have to ask the question, how fast does one need to be going, on a motorcycle, to kill it? What was the impact like? When now pondering this mechanism, it became clear the force was devastating (clearly for the horse) but, that also transfers to the patient. Therefore, he needs to be evaluated as a major trauma.

Again, I need to stay constantly vigilant and sharp. It’s in the history that the magic happens. I find that I passively want to cut corners.

Take time to ask these questions:

• How good is my history taking?
• Am I being thorough or trying to get it done fast?
• Do I need to make a change in my approach before I get myself burned?

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