Quality Corner: Technology and Assessment

The great thing about medicine is it’s a practice. You’re always learning, provided you’re receptive to continuing to learn.

There is no shortage of learning necessary in 21st century medicine. There have been more advances in medicine in the last 20 to 30 years than in the last 2,000 to 3,000 thousand years, which is quite mindboggling if you think about it. We now have CAT scans which can display three dimensional images of all the internal organs of the body, surgery where an appendix or gall bladder can be removed by a laparoscope inserted through a one-inch incision in the umbilicus and cardiac catheterization with angioplasty which can instantly reopen an occluded coronary artery, stopping a heart attack in its tracks.

Advances in technology are also becoming increasingly present in EMS, which is both good and bad news. One of the greatest pitfalls of technology of any type is it tends to draw attention away from the patient. Instances of this have become apparent to me as I’ve performed concurrent quality improvement audits observing EMS providers on calls.

I’ve seen instances of technology distraction by all EMS providers including myself over the years, with newer, younger providers seemingly being slightly more vulnerable for longer periods of time. Perhaps this is due to the fact that they’re more dependent on technology because it’s always been available to them.

Some medics I’ve observed are more likely to totally rely on technology for their initial assessment only to realize belatedly that a vital sign they bought into up front was wrong.

Being a medic for some 35 years myself, the very first thing I’ve always done is take note of the patients general impression as I approach them, then evaluate the strength, rate and quality of their radial pulse as well as their skin temperature and texture and capillary refill as soon I reach them. This is in essence a 10-second assessment of their mental and cardiovascular status. If their radial pulse is very weak, their skin is cool and their capillary refill is delayed, and I’m given a blood pressure of 150/90 I instantly know to at least question it.

If the EMT or machine is having difficulty obtaining a blood pressure, my 10-second assessment has already confirmed why. Old habits are not always bad habits.

Technology distraction is nothing new. Even veteran EMS providers will remember the old ACLS admonishment to treat the patient not the monitor. But the more electronic, blinky, beeping machines you surround a patient with, the more potential there is for your attention to be lured away from the patient. All of these technologies have their purpose, but in the grand scheme of patient assessment, they’re all just a piece of the puzzle.

ECG’s can show a perfect normal sinus rhythm despite there being no cardiac pumping at all, also known as pulseless electrical activity. Pulse oximetry can show 100 saturation of presumed oxyhemoglobin, which might instead be carboxyhemoglobin, or just an erroneous reading.

Any experienced user of non-invasive blood pressure monitoring know it has the potential of giving you any numbers at all with no correlation to the patients actual blood pressure, especially as it cycles as you’re bouncing down a pot hole ridden road in Pennsylvania. Any piece of equipment can fail just as any human can misinterpret.

The best approach to patient assessment is to use all the technology at your disposal, but not totally trust any one piece of data until it proves accurate in relation to all the other data and the overall presentation of the patient. You should only trust what makes logical sense to you.

Anyone can take a blood pressure or pulse or temperature. These measurements of course will not always be obtained correctly or be accurate.  

Acquiring these measurements is the science of medicine. Interpreting them based on comparison, evaluation and experience is the art of medicine. Contrary to popular opinion, it’s the art of medicine that will always be greatest challenge and most important part of medicine and EMS. 

Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He serves as the quality coordinator for both of these midsize third-service agencies in Southeastern Pennsylvania. Joe has over 35 years’ experience in EMS. Joe is also the author of the book; CQI for EMS–A practical manual for QUICK results and, in 2014, founded the National Association of EMS Quality Coordinators (NAEMSQC). Contact Joe at jhayestpc@gmail.com.