Close the Loops

EMS responds to a single-family dwelling, where they find an 82-year-old male patient with difficulty breathing and an "oppressive ache" in his chest. Onset was about 45 minutes before he called 9-1-1. He tells the EMS team that the pain today is much worse than the pain he had with a previous MI three years ago. As the patient assessment progresses, the cardiac monitor is applied and a type II second-degree heart block with a rate of 40 is noted. Vascular access is established and high-concentration oxygen is delivered, as are four baby aspirin. One sublingual nitro is administered with no effect, and the pacemaker is applied and attains capture. The patient is transported to a heart center and turned over to the ED staff without incident.

   All in all, one could make a decent case that this call was a success story, and, for the most part, it was. While the case was by no means overwhelming, it did present with some challenges worth discussing, especially in regard to one loose end that remained unaddressed.

Multiple Complaints

   As is often the case, patients frequently present with multiple facets relative to their situation. In the case above, we have a patient who actually has a two-part chief complaint, i.e., S.O.B. and chest pain. He also has a potentially lethal cardiac rhythm that requires attention. In actuality, there are three distinct elements of the care plan that need to unfold for optimal care to be rendered to this patient.

   Application of high-concentration oxygen quickly targets the breathing problem, and the pacemaker provides a temporary fix for the potentially lethal cardiac rhythm. But what about the "oppressive ache" the patient complained of? At some point during the call, this complaint fell by the wayside.

   When managing any patient with multiple needs, it's easy to get distracted. Once we make that initial connection with our patient and the information starts coming our way, providers often choose not to interrupt the flow. Whether it's the start-stop-start-stop problem that makes for choppy information-gathering, the matter of reconnecting with the patient, or both, the temptation is to keep a good thing going. The downside of this is that you can inadvertently be led away from your game plan.

   In the case above, pain management was never really executed, as only a single dose of nitro was given, with no additional pharmacological support whatsoever. The old argument that "pain never killed anybody" is partially true, at best. A patient with severe pain stays in a physiologically high-stress environment, often fueled by catecholamines poured out by the body when it is in the fight-or-flight mode. The last thing a dying heart needs is to be put under additional stress to perform.

Ongoing Assessment Is Key

   One of the simplest and most efficient ways to avoid letting things go astray with your patient care efforts is to make absolutely certain that you always perform a thorough ongoing assessment during patient transport. In reality, that is often easier said than done.

   During transport, there are usually one or two rechecks of vitals, as well as a recheck of breath sounds. Then you have to organize your patient care information and deliver your short report. As you near the receiving facility, your focus shifts to the upcoming transition and getting the patient off house Os, disconnecting the NIBP, etc. That's a lot to do, especially if you are the sole care provider. With all that going on, it's easy to see how the ongoing assessment can go by the wayside, especially if the patient remains stable. Still, the ongoing assessment is too critical to patient care to forget.

   The ongoing assessment should focus on two distinct areas: reassessing the ABCs and revisiting the patient's chief complaint(s). First and foremost, the ongoing assessment needs to confirm that the patient's airway is open and remains patent, that breathing is adequate, and that there is no circulatory compromise. Any problem(s) noted with airway, breathing or circulation require immediate attention. The second half of the ongoing assessment is going back and revisiting the elements of the chief complaint. These are the items that can easily become loose ends during the time the patient is under your care. In the case above, the loose end of pain management remained just that: a loose end that went unaddressed.

   By closing the loops on any loose ends, you make certain that whatever patient care therapies you have put into play have actually been effective and that you've met your patient's needs. Had a thorough ongoing assessment been completed on our patient, it's likely that one or two more rounds of nitro would have been administered, and possibly morphine sulfate or fentanyl to take the patient as close to pain-free as possible.

   In our case, the loose end of pain management did not result in a horrible outcome for the patient, but as a result, he stayed in pain and misery far longer than was necessary. Take time to do a thorough ongoing assessment with every patient, and you can drastically reduce the number of loose ends in your practice. Just close the loops.

   Until next month...

Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of the EMS World editorial advisory board.