Patient Assessment......The Lost Art

I've been reading some blogs of my mentors lately and they both have the same complaint. I figured that since I'm still relatively new to EMS I'd share some with them.

Patient assessment is one of those "skills" that develops over time. No amount of class time can help a student put the pieces together. We are taught signs and symptoms to look for but its very hard to visualize your fine looking mannequin with chest pain, sweating and pale. A good student looks for the things they have been taught and then also looks at what the preceptor picks up on and tries to put it together. Too often many new students say "We were taught this way" and I say so what. You can teach a monkey how to do skills but you cannot teach them how to interact with people. I don't care you were taught how to push a medication. If you can't tell me why you want to give that drug or you pick the wrong drug then you're not pushing the drug. End of discussion. You need to know what to expect once the medication is given and better yet that its the RIGHT medication.

I have learned a lot from JT and DJ over the past few years and I totally agree that the machines should be used to confirm what you suspect. For instance, I had a patient last year that when I took one look at him I knew he was having a MI. Everything fit: sweating, slightly altered mental status, look of impending doom on his face, complaints of pain in his chest. We moved him from his location to a bedroom to access him better and when I hooked him up I saw the STEMI criteria that I need to call it. We went ahead and got him loaded up and went to the appropriate facility. This was supposed to be the patient that I could help and make him better. Unfortunately when the higher authority calls on you, its time to go. Once in the ER the doctor had said that he had a heart blowout. I'm not exactly sure what that is but the doc said there was nothing anyone could have done to help this man. I felt horrible.

It was after that call that I began a very hard nosed approach to my students. No you cannot check a blood sugar just because your patient is a diabetic and is mentating normally. I really believe that just because you can do a skill does not mean you HAVE to do that skill. Your patient does not need an IV because they have vomited twice. If they are actively vomiting then yes get your IV and please do me a favor and give them an anti-emetic. I'm a symapthy puker so I'd really appreciate it if you can stop it.

Too often I hear of my collegues agressively treating patients that I wonder why not just sit on your hands? I had a CHF lady that had relatively clear lung sounds. Initial pulse oximetry was in the low 80s and improved to 96% with a little oxygen. I did not go any further down the CHF protocol because I felt it was not indicated. All the research that I've read has said keep the pulse ox level above 94%. Now my newer collegues questioned why I did not start an IV, give neb treatments, Lasix and the like. My answer was simply sometimes the most basic intervention is all that is needed. When I talked about this patient with those that have been practicing for a long time they agreed with what I did.

Unfortunately newcomers to EMS are ready to sink tubes, start IVs, give drugs and such. I pride myself on my caring and compassion with my patients. I want to understand what they are experiencing so I can better judge what I need to do next. The patient with kidney stones and renal failure needs some morphine but she's got 1 vein and if I miss it, the hospital may have to do a major procedure to give her medication. She asked me not to start the IV so I didn't. Instead I held her hand and tried to calm her through her ordeal. And the best part, she thanked me repeatedly during the ride and once at the hospital.

Bottom line is, if you cannot figure out what is going on then you DO NOT get any "skills". I make all my students no matter what level they are at, start a patient assessment and give the radio report and talk to the ER staff. I had a preceptor early on in my education that said "someday you're gonna be back here by yourself and you're gonna have to do it". She handed me the radio and I did it. It was a horrible call in but that's the push I needed to start doing them.

Remember as I've said before sometimes the most BASIC intervention is all that is needed.