Clues to a Catastrophe

     EMS providers face many scenarios that require the rapid evaluation of patients and what treatments they need. At times, though, there's only so much evidence available to suggest what's going on. What can basic-level providers do to expedite the process of assessing and assisting the not-so-obvious critical patient?

     Consider the following case: Paramedics are dispatched to the scene of an unknown medical and upon arrival find a 47-year-old male complaining of flulike symptoms. He tells them he was awakened by chills and that he is experiencing difficulty breathing. He's been taking over-the-counter medication for his symptoms for the past two days, but it is not working.

     It would be easy to think this patient is merely experiencing the flu. However, the paramedics in this case opted to do a thorough assessment. Due to the man's difficulty breathing, they placed him on oxygen (12 liters via non-rebreather mask). They initiated an IV and applied an electrocardiogram monitor. Single and 12-lead ECGs were obtained, and the 12-lead revealed a myocardial infarction.

     The patient's vitals were stable (BP 156/88, HR 102, RR 22); therefore, the crew administered one (0.4 mg) sublingual nitroglycerin and 325 mg of aspirin (orally). In addition, they opted to give 5 mg of Lopressor (via IV). En route to the hospital, they transmitted the 12-lead ECG ahead to the emergency department physician, who evaluated it and concurred with the paramedics' assessment. This allowed hospital staff to start preparing for the patient's arrival and treat him without delay once he got there. The patient was taken directly to the cath lab and received a coronary angioplasty, and his heart muscle suffered no damage.

Basic Assessment Skills
     There are times when a patient's problem is obvious. However, a bigger challenge for EMS providers is the search for what is not so evident. At those times your assessment skills are invaluable. In the field you have a short amount of time to determine if the patient fits the "potentially unstable" criteria. It's a must-have skill for all providers.

     So how can we prepare ourselves to conduct thorough assessments and avoid the trap of missing important problems in our patients? As with most approaches that deal with rapid and critical decision-making, the top priority is having a plan.

     EMTs are taught to follow certain steps when conducting an assessment; these must be carried out in order to avoid missing a serious illness or injury. There is no doubt that, after establishing that the scene is safe, airway should always be the first priority. However, the assessment process doesn't stop there. It is imperative that the prehospital provider complete a full initial sequence consisting of rapid assessment of the airway/cervical spine, breathing, circulation, disability (e.g., major hemorrhage, neurological deficit), and exposing the patient (removing their clothing if needed). These steps, represented by the familiar mnemonic ABCDE, are all critically important. We will often deal with patients who appear to have only isolated injuries and need only focused assessments. But there might always be something more to the story, and it's up to us to find it.

     The BLS provider can assist the advanced provider in his work by periodically reassessing the patient as the call progresses. For example, a basic provider might ensure that a patient is still being oxygenated appropriately, recheck a patient's vital signs (every five minutes for unstable patients and every 10 for those who are stable), monitor the pulse oximeter and notify the advanced providers of any changes, make sure the electrodes to the ECG are still applied on the patient, assist with the blood glucose test, repeat a detailed assessment and much more.

     A good rule to remember is "assess, intervene and reassess." A thorough assessment is the foundation to appropriately treating your patient, and as an EMS provider, reassessing the patient is just as critical as the initial assessment. Patient conditions can change dramatically over the course of a call. Continued assessment and reassessment will allow you to make better treatment decisions.

Conclusion
     For BLS providers, especially those new to the profession, it is imperative to work alongside senior BLS or advanced-level providers and strive to strengthen your assessment skills and ability to anticipate the not-so-obvious. The case scenario described here demonstrated that a rapid and thorough assessment can make an enormous difference in a patient's outcome.

     Not all patients require detailed assessments, but many do, and their presentations can be misleading. It is always better to conduct a detailed assessment and make sure you don't overlook a clue to a catastrophe.

Orlando J. Dominguez, Jr., MBA, FF/EMT-P, is chief of EMS and public information officer for Brevard County Fire Rescue in Rockledge, FL.