Patient assessment: What's changed since the "good" old days?
Patient assessments have improved over time through more in-depth assessment protocols, supplemented by today's technology
By Art Hsieh
As I lean back in my EMS rocking chair, I think about the days when all of the assessment tools that EMS providers had at their disposal were their heads, hands, a stethoscope, and a penlight. Paramedics were afforded one more tool, a portable ECG monitor/defibrillator such as LifePak 5.
Oh, those were the days: giving unconscious patients coma cocktails (Thiamine, dextrose and naloxone); high flow oxygen for everyone; putting anyone who sneezed the wrong way into cervical spine precautions; and giving all chest pain patients nitroglycerin paste, spray and morphine sulfate — after contacting medical control and sending telemetry over the APCOR radio.
Oh, the joy of making narcotic patients vomit all over my boots! Watching cardiac patients dump their blood pressure because of undiagnosed right ventricular myocardial infarction (RVI)! Wrestling combative patients to the backboard! Hyperventilating patients into a higher plane! Yup, those were the days.
Alright already. We did what we could back then given the state of EMS technology and education about patient assessments. Over time, as we examined more and more patients, our "rolodex" of contacts grew and we became more precise in our assessments, and more accurate in the level of care we provided. If you stayed in the business long enough, you could become a highly experienced practitioner. Still, it was hard to avoid making certain errors in judgment, simply because we couldn't detect the clues necessary to make certain deductions.
So, unlike perhaps a few folks out there, I am an advocate for the assessment technology we have at our fingertips today. Not as a replacement for good, old-fashioned, hands-on physical exams and sophisticated history taking, but as a much-needed adjunct, a way of gaining additional information that would be difficult or even impossible to detect.
Take the RVI scenario, for example. Say it's a 52-year-old patient, overweight, with too much time on his hands, telling you he has two elephants sitting on his chest. He's diaphoretic, and his skin color is paler than his beige couch. You check his vital signs and his blood pressure is 110/64 and his heart rate is 106. Classic presentation for that MI, right?
You know your protocol book says to administer aspirin orally and nitroglycerin sublingually. And you would, except your 12-lead-capable LifePak 15 monitor an inferior wall infarct. On a suspicion, you move led V4 from the left side of the chest to the right side, and low and behold, there's a corresponding elevation of the ST segment, indicating that this is more likely an RVI, with a great potential to lose chamber refilling if you administer that otherwise indicated nitroglycerin.
So, wisely, you work to adjust the patient's position to a flat, comfortable position and provide perhaps a little saline bolus, before giving the vasodilator. You rock! And, more importantly, your patient is not harmed by your treatment and maybe even improves. Double win!
This is just one aspect of improved patient care through more in-depth assessments, supplemented by today's technology. I'm glad to have been in the field long enough to see the transition from the old to the new. Keep in mind, though, that equipment will not provide the compassion and intelligence to the patient's side – that's your job.