Patient Assessment: A Lost Art

AS WE ENTER INTO THE 21ST century, technology is moving faster than ever before. Our personal and professional worlds are filled with labor-saving devices and technology, both of which are supposed to aid us in our day-to-day functions. Emergency medical services (EMS) are no exception to this new phenomenon. The questions before us include, “Have we lost our ability to properly assess patients?” and “Are EMS providers relying too heavily on technology and not enough on their instincts with regard to patient assessment?” EMS personnel must remember the basics when conducting a thorough patient assessment and not rely too heavily on technology.


Photo by John M. Buckman.

Between 1978 and1982, the LifePak® 5 defibrillator made its debut. The esophageal obturator airway (EOA) was the primary prehospital advanced airway device. A “progressive EMS system” may have had 20 choices of pharmacological interventions. Body substance isolation (BSI) precautions were by far the exception rather than the rule. Conversely, in 2006, options for EMS have greatly expanded: BSI precautions are mandatory; 12-lead ECGs are commonplace; a seemingly endless supply of advanced intubation equipment is available; cardiac enzymes can now be done in the field; a progressive EMS system may carry as many as 50-plus medications in its arsenal; and pulse oximetry, rapid sequence intubation (RSI), and vital sign monitors are standard. The list goes on.

ATTITUDES AND DOCTRINES OBSERVED

As an EMS educator, I train students in the didactic and laboratory setting and observe them in the field and hospital settings. This luxury allows me to observe not only students in various settings but also the general attitudes exhibited by other EMS and hospital personnel in their patient care settings. I have seen the following attitudes and doctrines on a regular basis.

Why Exert Yourself?

In many systems, there is a certain undertone that says, if technology is available, use it not as an adjunct as its designers intended but to replace part of the patient assessment. The pulse oximeter presents a case in point: It can be a reliable adjunct to emergency care workers for determining oxygen saturation, provided it is used appropriately and there are no exclusion criteria that may alter accurate readings (i.e., carbon monoxide poisoning, the wearing of metallic nail polish, or the existence of a hypothermic state, for example). Virtually all pulse oximetry units give a pulse rate along with the oxygen saturation level. You should look at this as a bonus, not as a primary evaluation tool for a patient’s pulse. As we are all aware, the pulse oximeter does not tell us if the pulse is regular or irregular or if it’s bounding or thready. Although everyone understands this basic principle, I have repeatedly observed EMS providers using this adjunct as a primary evaluation tool for ascertaining a pulse.

The same is true for automatic blood pressure (BP) cuffs. Will they give an accurate reading? Yes, if the correct cuff size is used, if the equipment is being used properly, and if the operator is intelligent enough to physically reassess the BP if the reading does not look consistent with the patient’s presentation.

The more wires we hook up and the more readings we obtain do not necessarily mean we are doing a quality patient assessment.

Touch the Patient as Little as Possible

With communicable diseases on the rise, healthcare workers in general are less apt to perform the hands-on tasks they once did. This is taking into account that in the overwhelming majority of the cases, when basic BSI precautions are in place, the risks are very limited. However, EMS providers as well as other healthcare workers are not as “hands on” as they once were. This itself hinders the patient-assessment process.

Medicine is a hands-on business. As long as the appropriate precautions are taken, we should not be afraid or unwilling to perform a hands-on assessment in a diligent professional manner.

Time Is Valuable

Since time is valuable, don’t ask too many questions; you may get too many answers. This “hands off” philosophy seems to spill over even to basic conversation while communicating with the patient. A provider should ask many detailed questions to ensure optimum patient care. Instead, in many cases, if the question is not found in a checkoff box on the patient care report, it is assumed it must not be worth asking-a more FALSE statement has never been made. We are the first link in our patient’s emergency care. In fact, we are often the patient’s entry into the healthcare system. The more information we can obtain, the better picture we will have of the potential underlying problem and, therefore, the greater the chance that it will be treated effectively.


Phota by Ron Jeffers.

In some two-tiered EMS systems, the decision to transport advanced life support (ALS) or basic live support (BLS) (obviously depending on circumstances) is based on the information gathered from the patient. Vital information can easily be missed if the providers are not diligent in their efforts.

Don’t Look Only at the Obvious

Looking only at the obvious can cause you to miss something critical. Is this statement elementary? Yes, but yet this happens all the time. A patient with a disfiguring facial injury can occupy your focus while a life-threatening, small-caliber gunshot wound goes unnoticed. In one case, a 14-year-old teenage girl collapsed while dancing at a school function. EMS responders found the girl in full cardiac arrest and proceeded to work her as a medical “code.” It was not until they delivered the teenager to the emergency department that the small-caliber entrance wound in her left chest was discovered. Apparently, the young lady was shot while dancing. Because of the loud music, no one heard the gunshot. Further, EMS did not conduct a thorough head-to-toe examination and, as a result, missed the cause of the teenager’s collapse. Make sure you do a full evaluation and are not distracted by the obvious, especially in high-pressure situations. A rapid head-to-toe exam-also known as a rapid trauma exam-which searches for DCAP-BTLS (deformities, contusions, abrasions, punctures-burns, tenderness, lacerations, swelling) could have avoided the missed gunshot situation above, and EMS would still have conducted the trauma assessment within the time requirements.

GETTING BACK TO BASICS

EMS is a “people” business. We are called to assist our patients at their time of greatest need. We should not take this responsibility lightly. It is essential that we provide optimum care by following some simple guidelines:

1.Carefully evaluate the ABCs (Airway, Breathing, Circulation) and AVPU (level of consciousness-Alert, Verbal, responds to Pain, Unresponsive). Address any problems you find efficiently and diligently.

2. Employ SAMPLE (Signs or Symptoms, Allergies, Past medical history, Last oral intake, Events leading up to) and OPQRST (Onset, Provocation/Palliation, Quality, Radiation, Severity, Time-or like questions). Thoroughly ascertain the information specified in the mnemonics, and document it accordingly.

3. Manually take at least three full sets of vital signs, and use advanced diagnostic equipment for its intended use. Remember, you are treating the patient-not the equipment.

4. Depending on the situation, perform the appropriate physical exam diligently-look beyond what you think may be wrong for other possible causes.

5. Talk to your patients; they are your greatest source of information.

6. Be empathetic and courteous no matter what the circumstance.

7. Always err on the side of caution for your patient.

8. Abide by the “Golden Rule.”

9. Always act in a professional, diligent manner; never fall into the trap of laziness. Laziness can cost a life.

10. Always check all your equipment at the start of the shift to ensure it is present and in good working order.

The art of patient assessment starts with the provider’s work ethic and attitude. Following the guidelines you have been taught, abiding by your protocols or standing orders, and using your instincts are vital to performing a proper and thorough patient assessment. Use the tools of the trade, the advanced technology, as adjuncts to patient assessment, not as the primary or only source of patient information. As EMT textbook author Harvey Grant observes, referring to becoming so entrenched in using the fancy technology that we forget a simple premise, “When you put on a Band-aid®, the sticky side goes down.”

FRANC FEROLA, BA, EMT-P, LP, is a paramedic and managing partner of U.S. Public Safety Solutions LLC, a consulting and education provider based in Florida and Texas. He also is director of operations/EMS training coordinator at Health Career Institute in Lake Worth, Florida, and a volunteer firefighter/paramedic with Palm Beach County (FL) Fire Rescue.

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