Every so often, an experience paints a clear picture of a situation. Sometimes that picture contains a surprise. Several years ago, when I was an EMS captain, a nurse whom I respected approached me. She told me that our paramedics were not treating women with chest pain or shortness of breath the same as they were treating men. That didn’t seem possible to me. Yet, she was exactly right.

Looking at an equal number of male and female patients (10 each) who had complained of chest discomfort with associated shortness of breath and were admitted to that hospital’s chest-pain center, we found that EMS had worked up 80% of the women for anxiety. In contrast, 80% of the men were worked up for myocardial infarction. Upon learning this, I apologized to the nurse and thanked her for bringing this to our attention. More importantly, we created a continuing-education unit to address this apparent inconsistency in treatment. It was a humbling experience that reinforced the importance of listening to everyone on the healthcare team.

As a chief officer, I truly miss day-to-day involvement in emergency medicine — especially the interaction with patients. So, when an emergency occurred recently during my return flight from Indianapolis, where I had attended FDIC, I was happy to be in the right place at the right time to help and to potentially make a difference in someone’s life. I saw that a flight attendant in the row in front of me had an oxygen tank slung around her neck; I then saw her place a non-rebreather mask on a female passenger in that row. When I heard the flight attendant ask her counterpart to see whether a doctor was on the flight, I volunteered to take care of the patient and identified myself as a fire-department paramedic.

A quick assessment revealed all the signs and symptoms of hyperventilation. Eliminating the oxygen and having the patient re-breath into the mask brought the numbness and tingling under control. Using the medical equipment on the plane, I became convinced that the problem was hyperventilation and relayed that assessment via the onboard Medlink communications system. For the next 20 minutes, the patient was thoroughly questioned about her compliant and the history leading up to it; a stroke assessment was done, and vital signs and lungs sounds were checked over and over — the works.

Eventually, the symptoms changed to numbness in the right arm and the rest of the story revealed itself. The patient revealed that she had experienced chest palpitations twice prior to boarding the plane, as well as a heaviness or “hard-beating heart” during the first stage of the three-hour flight. At age 48, she had a history of neuropathy and a family history of cardiac issues. After 20 minutes of persistent “dullness” in her right arm, I asked the flight attendant to use Medlink to request a priority landing.

The flight crew flawlessly followed the procedures for an in-flight medical, which is a tribute to the training and discipline of commercial aviation. This, in essence, is the moral of this story.

In the meantime, the patient received an aspirin. I explained to her that the receiving airport has paramedics and that they would be meeting us upon arrival. I went on to tell her that the fire department at this particular airport is one of the best in country — nationally known for great customer service — and that they would take great care of her.

Then my own anxiety started to kick in — what if we landed and the fire-based EMS crew that meets the flight dismisses the updated information in favor of the first Medlink message that indicated the problem was hyperventilation? I wondered whether I would have to advocate for the transport to rule out myocardial infarction — and how to do it tactfully. Living in Nevada and having worked on the Las Vegas Strip as a young paramedic, I more than once discounted a bystander who claimed to have medical training.

“Recognition primed decision-making,” or RPD, has served those of us in emergency services well; if it sounds like a duck, it’s most likely a duck. Indeed, RPD has been the basis for most fire-service training and decision-making. A field internship is based on the same principle, which is that you must see particular types of calls to know how to process them, i.e., having seen something before imprints the experience. But while RPD is the basis for our decisions in EMS and tactical scenarios, when ambiguity exists in a situation — particularly one that does not fit the norm — it is communication that allows us to adapt.

Unfortunately, the demands of increased call volume and other duties have retarded our ability to listen well. Time is a precious commodity and crews are pushed to get back into service quickly. As a result, the world relies on snippets of information to draw conclusions. Because of this, I worried what the jetway door would bring.

When the door opened a BLS squad with three firefighters and an officer greeted us. Within two minutes the captain asked for ALS. An ALS engine arrived within six minutes, followed by an ALS fire department transport within eight minutes. As each crew arrived, members not only listened to each other, but also to the words of a stranger. And while the ALS engine wanted to believe all was well, as the machines indicated normal values for the patient, the paramedic did the right thing by encouraging the transport — even though his body language told me that he wasn’t sold on the idea.

We spend a lot of time preaching the command sequencing of recognition primed decision-making, and it is ingrained as a thought process in emergency services. The difference between fireground and EMS recognition prime decisions is in the former; feedback is provided by the end of the call, but in the latter it rarely is provided at all. As a result, feedback regarding missed diagnoses and their consequences rarely finds its way back to crews.

Ironically, I had to leave FDIC early to attend a meeting at the National Registry about how we can put crew resource-management principles into the testing process, in order to help eliminate errors in patient care. This is vital, as a medication error or misdiagnosis can cost a life — a dynamic I experienced first-hand on my flight from Indianapolis. The experience gave me a clearer picture and a stronger conviction on why crew resource management must be put into everything that we do.

Bruce Evans is the EMS chief for the North Las Vegas (Nev.) Fire Department. He also is an adjunct faculty member for the National Fire Academy's EMS and injury prevention courses.