BY TIM PERKINS
Have you ever thought about how many different factors come into play on every emergency medical service (EMS) call to which you respond? What about how these factors determine how you approach the patient, interact with the patient and bystanders, treatment, and transport-not to mention how any one of these factors may affect your safety and that of your crew? The possibilities are as varied as the calls to which EMS providers are dispatched daily.
All these factors can be considered “EMS clues,” and using your skills as an EMS provider-or “EMS detective”-can help you to be cognizant of scene safety, scene assessment, interview of patient and bystanders, assessment, treatment, and transport.
There are so many variables, even when driving to the station for a shift. Think about the day of the week or the time of day: Would you be more apt to be called to an assault on a Tuesday morning or a Friday night? Will you be “busier” at 7 a.m. or 7 p.m.?
Weather can play a role. You may need to keep extra blankets in your vehicle when it is cold. You may need extra ice packs when the weather is warm. Maybe you’ll have to carry a shovel in winter to clear a path to access a patient or perhaps store a tarp in a compartment in rainy weather.
System issues may come into play. If you work in a busy system, how many other vehicles are in service? If you work in a more rural area, how long will your response be? How long will a hospital transport take? Are there facilities that you may not be able to reach because of diversion or capabilities [stroke or STEMI (ST-Elevation Myocardium Infarction), for example]?
Your dispatcher may also provide you with information you can use as clues. Does the dispatch address sound familiar as a place to which your agency responds often? If you have “1313 Mockingbird Lane” burned into your memory, there is at least a fair chance you might know what you are in for. Is it a place where you know you may have trouble getting access to the scene, the house, or the patient? The type of call is always a consideration, as well as whether or not prearrival instructions are being given. Finally, the dispatcher should advise you if he deems the scene to be potentially unsafe (such as having law enforcement en route or on scene), and you and your crew should act accordingly.
Once you arrive on scene, there may be clues right off the bat. Of course, most times you’re not going to roll up on a mushroom cloud or a car into a storefront or a crowd of 500 people, but there are things you might see on scene that will provide clues such as a starred windshield, significant intrusion into a vehicle, the presence of a body fluid (blood, vomit, and so on), the presence of a liquid (hazardous or not), and also the conditions on scene (disheveled house or bar, for example). This information provides you with potential clues not only about patients but also about access to those patients.
Remember at all times that your safety and that of other providers are paramount. If it does not feel right, it usually isn’t. Always ensure your and other crew members’ safety on the scene, even if it necessitates the use of law enforcement.
There are tools that the EMS detective needs to be able to do the job. Most of them you, the EMS providers, have had all your lives: eyes; ears; mouth; nose; hands; and, of course, brain. You will also need a scratch pad or patient care report and a pen. Finally, you will need the equipment or medications to properly treat and transport the patient.
Eyes. Your eyes may be the most important sensory tool you have as the EMS detective. Paying attention to the most obvious visual clues and those that may not be as obvious will aid you in your assessment and treatment.
What does finding an empty pill bottle mean? Has the patient finished the prescription, or could it be an overdose? Check the label. Is it something that was prescribed for the patient? If the date is old, is the patient compliant with that medication? What if you encounter a patient with a nasal cannula and 30 feet of oxygen tubing? If you discover a lot of syringes lying around, does the patient have diabetes, or is he an IV drug user? If the windshield is cracked, did it happen in a crash today, or did it happen previously? If a child has a separated shoulder, is it accidental or from abuse? If you find a cigarette burn on an elderly person, is it accidental or intentional? These are just a few of a myriad of clues you may see that will help you to assess and treat the patient.
In addition, the medications patients take provide clues to their injuries or illnesses: If your patient takes digoxin, you know he has a cardiac history; the same applies to nitroglycerin. If the patient takes Dilantin® (phenytoin), you may suspect seizures. Be sure to check the labels of the medication bottles. Is it something that is prescribed for the patient? If the date is old, is the patient compliant with that medication?
Ears. Your ears are just about as important as your eyes. You hear not only sounds through a stethoscope but also what is going on in the environment. If your patient has crepitus, what could that mean? What if his speech is hoarse? What does it mean if he has an audible clicking in the chest? Breath sounds are also important clues to note.
Much of the information you gather is gleaned from answers to questions you ask, which also involves verbal communication. Verbal communication is essential in gathering clues. Interviewing the patient, family, bystanders, other public safety personnel (other EMS, fire, and police) will be of value.
The EMS detective should conduct a line of questioning in a manner similar to that used by law enforcement in an interrogation. That said, the EMS detective should remember the five “Ws” as well as “How”:
Who: Ask the patient his name, the place, the time, and other questions to determine his mental status.
What: What is happening today to bring EMS to your location? Is this illness/injury new to you? Develop a past history, list the medications, determine if there are allergies.
When: When did the event begin? What is the duration?
Where: What are the specific pain points, injury sites, and referred pain points (if present)?
Why: Are there any exacerbating circumstances (mechanism of injury, disease process)?
How: What is the patient’s rate of pain on the pain scale? Is there anything that provides relief?
When interviewing patients, try to keep a consistent form to your questioning for each patient:
- The chief complaint.
- The present illness.
- Past medical history and current medications.
- All of the appropriate mnemonics, including the PQRST Method for Pain Assessment (Provocation, Quality, Region, Severity, Time)and SAMPLE History (Signs and symptoms, Allergies, Medications, Past pertinent medical history, Last oral intake, Event).
- Personal, social, and family history. Include questions that may rule out injuries or illnesses. In many situations, symptoms they might have but do not have are as important as symptoms that they have.
Also, remember that there are clues that can be gleaned from others on scene. Many times, they can provide you with useful information, even more useful than you receive from the patient, especially if the patient has an altered mental status.
Smell. This may be the most difficult of the senses. Your own olfactory system is important to finding clues, no matter how unpleasant those smells may be. Many EMS providers can regale you with stories of being greeted at the door by some of the most repellant odors imaginable. There are several medical situations that cause smells that are easy to detect as you set foot in the door of a residence. Some of these odors include a deceased person (especially if dead for any length of time), GI bleeds, urinary tract infections, sepsis, and gangrenous or necrotic tissue. There is also the “fruity breath” of patients in diabetic ketoacidosis (DKA), which some describe as “fruity” and others describe as “nasty.” Discharge is another unpleasant odor. These smells provide clues for the EMS detective.
Touch. Your sense of touch is also extremely important, especially during the assessment of your patient. Remember that the clues may be quite obvious or very subtle. Look for the presence or absence of pulses (at different pulse points, if appropriate); deformity, rigidity; fluid or air in open spaces; tenderness or guarding by the patient; and body temperatures, both warm and cold. A thorough assessment includes patting down the entire patient.
Using all the tools above, the EMS detective should be able to put all the clues together to form an impression of the patient’s injury or illness, combining the clues as well as your instinct, education, and experience. This impression should be your opinion based on the information you gathered.
Be sure to use a scratch pad or run report to help document your findings. Be as specific as possible about all the clues you have found: all the things you saw, heard, asked, smelled, and palpated. These are the “facts of the case” to decide patient treatment and transport.
Going into every call you respond to thinking in the same manner as a detective, with consideration of all the aspects of the scene and use of your sensory abilities, education, and experience, will be important in assisting you to determine the most appropriate patient treatment and transport.
This article is based on my experiences as a basic life support and advance life support provider. For additional information, consult EMS training materials as well as those specifically dealing in anatomy and physiology.
TIM PERKINS is the EMS systems planner for the Virginia Department of Health, Office of Emergency Medical Services in Richmond. He has nearly 25 years in the emergency medical service as a provider, an administrator, an author, and a speaker.
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