What can we do to help improve the quality of patient care by our providers? That’s a question every serious quality coordinator has asked. The question is simple, the answer not so easy. The array of EMS providers at any agency will run the full spectrum of experience and skills. I’ve thought a lot about this question and discussed it with some of the people I consider to be the best EMS providers.
The three things I’ve settled on telling new medics I precept to help improve their proficiency are:
- Assess your patient early and often.
- Maintain a high index of suspicion.
- Do call research.
Assess Early and Often
The first and most important thing any EMS provider should do is assess their patient. You can’t treat them if you don’t know what ails them. Sometimes what ails them will be obvious at a glance, others it may take a whole lot more time, tests and smarts than just 15 minutes with a paramedic will allow, but we should always make the effort to figure out what’s going on with our patients.
Patient assessment is job number one of EMS. This assessment should begin without delay, immediately upon making patient contact and be documented as such. Of course, obtaining a full set of vital signs should be done as soon as possible, but occasionally obtaining a blood pressure or pulse ox may be delayed due to an uncooperative patient or the patient being entrapped, where certain interventions take priority.
In these cases a rapid patient assessment should be performed, noting the general appearance of the patient, skin color, capillary refill, and rate and quality of their pulse. This should provide a quick and fairly accurate read on the patient’s cardiovascular status. The blood pressure and pulse ox should still be acquired as soon as is practical to confirm these findings. But with or without obtaining a BP or pulse ox, you should assess your patient as completely and as soon as possible, and document that assessment as having been completed. It looks horrible if no assessment or vital signs are documented for several minutes after patient contact and leaves the reviewer to wonder what the providers was doing all that time if not performing their initial assessment.
Beyond assessing your patient early, your assessment should also be ongoing. Disease is a dynamic process. The one thing that can be guaranteed is that your patient’s condition will change from minute to minute. Changes may be as simple and inconsequential as a slight decrease in their heart rate as they’re reassured and calm down, or it may be more dramatic and critical as having a change in their level of consciousness, or degenerating into respiratory or cardiac arrest. If you are not constantly reassessing your patient, you may miss something very important.
As with your initial assessment, don’t forget to document your re-assessments. Repeated documented assessments and vital signs are proof that you did, in fact, continually re-assess your patient. And in most cases after you start treating a patient, subsequent vital signs will demonstrate an improvement in the patient condition, which will prove your treatment was appropriate and make you look good.
Index of Suspicion
At this point in time, it’s a pretty well-established practice to over-triage trauma patients to trauma centers. EMS providers consistently do this based solely on mechanism of injury and the suspicion of potential injury. As an International Trauma Life Support (ITLS) instructor, I believe one of the most important pearls of wisdom in the provider manual is the one that states, “5% to 15% of seriously injured trauma patients will initially present with normal vital signs and no sign of anatomical injury.” The obvious reason for this being you can either bleed slowly or you can bleed fast. Fast bleeds will be obvious, slow bleeds not always so. Consequently, it is rare in most places nowadays for a seriously injured patient to not end up at a trauma center.