Three Big-Money Questions

Truth be known, I’ve had an ongoing fascination with the patient assessment process for most of my career. Each and every provider with whom I’ve ever worked had certain subtleties and nuances to the way they obtained information from their patients, just as I did.

Once you meet and greet your patient and start the assessment process, the actual questions that get asked, how they get asked and the sequence in which they get asked can each alter both the volume and quality of information you obtain. However, over the years I have found there are three questions in particular that I refer to as “big-money” questions—i.e., the time you invest in asking them will yield big returns in what is gleaned from the answers.

1. How does the patient present?

Primary benefits: safety assessment, qualification of sick/not sick.

The moment you walk into any emergency scene, you get a brief opportunity to “snapshot” the initial presentation of the scene and your patient. Finding your patient half-slumped over an easy chair, beer in hand and smile on face, saying, “Hey, what are you guys doing here?” is far different than meeting the same guy standing in the doorway, legs spread wide with arms crossed over his chest, a scowl on his face, asking you the same question. Hostile or aggressive postures, loud responses and overly animated movements can all point to a patient who is for some reason spun up. My experience has been that spun-up patients are much more likely to result in safety issues than overly subdued or obtunded patients.

Skin color can provide quick and helpful information about perfusion, with overly pale skin and the dusky blue tint of cyanosis both being big red flags. When you touch your patient as you greet them, that cool slimy-sweat tied to sympathetic discharge is another indicator you are dealing with a really sick human being. A quick pulse check can also yield big dividends as you note whether it is particularly slow, fast or non-regular.

Noting excessive work of breathing should also move the sick/not sick meter toward sick.

2. What is the patient’s level of consciousness?

Primary benefits: Evaluation of “reliable historian” status; further refining of sick/not sick status.

There are multiple methodologies for assessing a patient’s LOC. While clearly being the simplest, the AVPU query doesn’t yield much other that what your patient is responsive to. A&O x 3 or 4 (person, place, time, plus knowledge of events) provides insights on long- and short-term memory. The GCS is most helpful and replicable, as it yields insights on overall brain function as you assess eye opening along with verbal and physical responses.

At some point, whatever methodology you employ, you have to decide if your patient is a reliable historian. Clearly, the more reliable your patient, the more you can use the information you extract during your assessment with confidence. By comparison, information squeezed from a hypoxic, markedly confused patient is much less valuable, forcing you to rely more heavily on your diagnostics.

One comment on assessing the patient with alcohol on board: This common situation alters your ability to assess pain because of the CNS depressive qualities of alcohol, but you can still extract valuable information (sometimes much more than you would like). But in the end, you are better off having more information to sift through than less.

3. What is the chief complaint?

Primary benefits: helps focus your assessment and care plan; comforts your patient; further fleshes out the sick/not sick status.

Whether it’s “Why did you call 9-1-1?” or “What brings us to your home tonight?” this big-money question provides you with the patient’s take on just what’s going on.

Once you have cleaned up the primary survey and identified and, if need be, corrected any immediate life threats to the patient’s airway, breathing, circulatory or neurological status, focusing your energy in response to the chief complaint will usually get your patient to calm down—a clear benefit regarding patient stability. When a patient tells you what they believe is wrong and you immediately begin to evaluate their complaint, at least for the time being, you have validated their concerns. Clearly your assessment may take you down other pathways, but as a general rule, following up on the what the patient perceives as being wrong today will generally get you more buy-in as you start to work your treatment plan.

Ultimately, matching the patient’s chief complaint with what the signs, symptoms and diagnostics tell you about their condition should firm up your “quantification” of how sick your patient truly is.

Conclusion

When it’s all said and done, getting these three questions asked and answered should set you up to do better diagnostic work and ultimately lead you down the path of quality patient care.

Until next month…

Mike Smith, BS, MICP, is director of clinical education and lead instructor for the Emergency Medical & Health Services program at Tacoma Community College in Tacoma, WA, and a member of the EMS World editorial advisory board.