A nugget of Big Medicine for your consideration. #94 The Three Paragraph Rule
Of all the diagnostic techniques I learned during my life on the streets, none has served me better than the Three Paragraph Rule.
Of course, a positive result for Hand Drop Over Nose (HDON) was much more dramatic and provided an immediate indication of actual level of consciousness. We used HDON to validate our suspicion that a patient was much more aware of our presence than he or she was pretending to be.
The call usually began as an undetermined emergency, a possible intoxication, or a suspected overdose. And for some reason, those patients almost always were found laying peacefully on their backs – usually on a comfortable bed or plush carpeting. Nary a grimace, a hand clutched to their gut, or any other expression of distress in sight. No pill bottles or other drug paraphernalia anywhere on the scene. Not even a bottle of near beer in the fridge.
Just a patient who had, for all intensive purposes, voluntarily fallen out. Despite all indications that the patient should have been able to respond to your questions, they scrunched their eyelids together and refused to interact with us or any others in the room.
At some point in the process, usually immediately after the transfer to the stretcher – when it was absolutely apparent that we were not hauling deadweight and the patient was actually cooperatively managing their body to ease the slide and carry, one of us would suggest checking for a positive HDON. In which the patient’s hand was lifted high over their face and then unceremoniously dropped.
If they were really unconscious, their hand would land with a thump on their nose. Of course, if they were really unconscious, we wouldn’t be screwing around with the HDON because we’d be too busy ensuring their airway was clear and their heart was still making little pitter-patter noises in their chest cavity.
Inevitably, just prior to contact with their nose, their hand would magically and mystically glide to the side and land softly on the pillow. And we knew they were positive for HDON and would require nothing more than supportive care and hand-holding en route to the ER where they were likely to miraculously regain full consciousness right after one of the nurses mentioned the possibility of using a tube the size of a garden hose to initiate gastric lavage.
Yes, that’s right – the source material for that time-honoured expression of our youth “Up your nose with a rubber hose.”
Sadly, despite the wonder of a positive HDON, its use is very limited in the real world beyond EMS. Not so for The Three Paragraph Rule.
According to The Three Paragraph Rule, anyone – anyone at all – can sound perfectly normal through the first three paragraphs of a conversation, discussion, speech, or interview.
It’s only after the third paragraph that he or she begins to loosen up just a little bit, let their guard down, and begin to talk about the collection of tinfoil hats amassed in the hall closet just in case the aliens in the apartment downstairs decide to teleport themselves into the bedroom – again.
And if you refrain from interjecting at that point in the monologue, you may be lucky enough to hear all about the very first time the aliens used the teleportation device in their microwave to send perfectly ripe grapefruits from Florida right into the fruit bin of the patient’s fridge. “And would you like to try one, kind sir?”
The Three Paragraph Rule continues to pay dividends to this day – and it works across the board, in real-time.
Political candidates: “I promise you that every Quebecois will have their own personal physician within 12 months.” “You need to put your faith in the universe that the economy will recover.”
Stump removal guys: “Yeah, and one time when we couldn’t get the trailer in there with the grinder on it we just used some dynamite.”
And my personal all-time favourite – the traffic lights controller: “I control the traffic lights with my mind. I can turn all the lights green just by looking at them. I’m so good at it that I just close my eyes and drive through the intersections because I know the lights will turn green for me.”
And so began the fourth paragraph as we worked to extricate him from the wreckage of his car after it was struck by a city bus when he shot through the intersection of Peel and Sherbrooke on a red light.
Thanks for your consideration.
Be well. Practice big medicine.
Hal
