Assessing Greatness – Catching the stuff you’re supposed to

What the heck is wrong with this guy!? You just can’t figure this one out and your patient seems to be crashing before your eyes. You were originally called for the “Unconscious unknown” at a party house frequented by college students and found the 28 or so year-old male unresponsive. Everything you check seems to be a dead end. His heart rate is fine, but slowing… His respirations are adequate but you’re certainly considering getting out the bag-valve-mask… You’re popped your line and given 2 full milligrams of Narcan but that hasn’t had any response. His pupils are PERRL but sluggish. His skin is pale, cool, and moist but not diaphoretic… and there doesn’t seem to be any trauma. Everything with this guy is a dead end treatment wise and you decide that this guy simply needs to be treated with diesel. You have your partner hop up front, turn on the twinkles and the woo-woos and beat feet to the hospital. All the way you check and recheck, trying to figure out if you can fix this guy. Unfortunately, you don’t make any headway before you reach the ER.

After you finish cleaning and restocking the truck to return to service from the ER you walk past the patient’s room on your way to get a cup of coffee. You’re shocked to see that the patient is sitting up, is alert and talking, and seems to be doing just fine. Incredulously, you ask the nurse what happened. She asks you what the reading you got for the patient’s blood sugar in the field was, and before your mouth can speak, all of the voices in your head seem to scream at you in unison “Holy Flying Pig Tarts!!” you forgot to check the patient’s blood sugar, thinking that it was most probably a narcotic overdose. The ER didn’t however, and found that the patient’s blood glucose was 20.

Have we all been there? Can we just admit that we all have found ourselves in this or a similar situation at least once or twice in our storied careers? As much as I am ashamed to admit it, I have found myself in similar situations where it seems I just messed up and left out an important part of my assessment. Somehow, something important like taking a quick blood glucose reading on an unresponsive is going to slip your mind somewhere in your career and in your adventures in the field and it’s going to bite both you and your patient in the hindquarters. Mistakes, or rather oversights like this are all too common in all branches of medicine because we as the healthcare professionals are simply human beings trying to absorb and process way too many pieces of information at once.

Much has been decried about the practice of “Defensive Medicine” where healthcare providers, mostly physicians, order unnecessary tests simply to avoid missing an obscure case and being sued because of it. People are constantly irradiated for unnecessary X-Rays, CT scans, and other such tests or so say the detractors of these practices. They say that it exposes patients to unnecessary testing, causes a false sense of security, and drives up the costs of healthcare exponentially. Popular culture has even jumped on the bandwagon, with the heroes of popular medical dramas coming out against the practice and being regarded as cowboys or mavericks. The public then eats it up… until they have a headache and don’t get a CT scan to ease their worried nerves.

However, not all practice of defensive medicine is a bad thing and in fact, in EMS I believe that this practice can be a good thing. I have long believed in my career and in my professional paramedic practice that every patient deserves a thorough and standardized assessment. Sure, I am pretty darn good at coming up with my working diagnosis based upon my solid initial assessment with a few secondary and tertiary assessment tricks to narrow in on the diagnosis and get my differentials, but the foundation remains the same. Everybody gets the same head to toe assessment. I’ve standardized it so that I don’t miss anything… or at least that I don’t miss as much as is possible not to miss. Standardizing your assessment and performing the same assessment on every patient every time becomes a security blanket and helps keep your assessment skills sharp with every call. Sure, it may seem silly to listen to lung sounds on a patient with a twisted ankle, or to check pupil reaction on the finger amputation, but you don’t have to let the patient know you’re doing it. Just look at them. Make sure you hit every high point in your standardized assessment with every patient, and you’ll catch a lot more zebras than you’ll miss.

In addition, there are some ground rules that I follow with certain types of patients and those fancy diagnostic tools that they give us to play with. First and foremost, if they say that skin condition, color, temperature, and moisture is the fourth vital sign, then blood-glucose level is the fifth. Sure, not every patient needs a lancet poked into their finger to have the machine read the number, but certainly every patient with an altered level of consciousness does. Even if you think the cause of the patient’s condition is something else, like the patient I had the other shift who was hypotensive and septic with a high fever, check it anyway… because the patient in the above example had a blood glucose of 40mg/dl and responded quite well to some fluid and the D-50 I gave him. Other patients who may not need to be poked can still have hyper of hypoglycemia ruled out by asking them their bladder habits (hyperurination), their last oral intake (Have they eaten enough not to be hypoglycemic) and other sugary questions.

Then, there’s the 12-lead. Can I just say that I see darn near close to zero reason that every patient who gets into an ambulance cannot get a 12-lead EKG done on them? To be sure, I don’t give every patient a 12-lead… but for anything that could be even remotely cardiac related I will perform one. Lethargy? Check. Flu like symptoms? Check. Syncope or near-to-it? Check and Check. It takes only a few minutes to perform and you can really make a difference in a patient’s overall healthcare pathway and well being by taking a symptomatic 12-lead tracing and starting the trend of monitoring. Before we all had the tool (Sorry Chicago… you should be catching up with the rest of the world soon) just how many ischemic cardiac events went undetected?

The crime here lies firmly in the realm of the underassessment, not in overassessing. The patient assessment is the cornerstone of everything we do and takes priority to all but the airway, breathing, and circulatory status of all patients. Making sure to be thorough and methodical in your assessment practices saves not only lives, but your own butt in the process. You cannot over assess just as you cannot overeducate yourself as to what potential findings mean. Just as an EMT basic can ask the same questions as the most seasoned paramedic, they can also ask the same questions as an ER doctor with the proper self education.

EMS needs to see itself as playing a role in the overall healthcare system and in the final care pathways for the patients we treat. Becoming an expert at the patient assessment is a big role in this. Remember, you’re the person who sees the patient in the first stages of their acute illness and in their entry into the healthcare system. Your thorough assessment goes a long way into the wellbeing of every patient you touch. Be great at it.

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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.

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