One of the more difficult aspects of prehospital medicine is achieving entry-level mastery of patient assessment. You must initially learn the basic format, then learn how the evaluation "tool" works. Collectively, it adds up to a lot of memorization.
Then comes the real challenge-turning the textbook format into functional street medicine. For example, your patient care report requires you to check on the patient's "last oral intake." In reality, if you asked your patient "What was your last oral intake," the reply would be something like "Huh?" The original question, properly translated into layman's terms, would simply be "When did you last have something to eat?" Bridging the gap between the medical terminology you have been trained to read and understand and the countless ways people try to explain their current conditions is no easy task.
One of the greatest communication challenges in prehospital medicine arises when assessing and treating patients who are seriously short of breath. Normally, practitioners are taught to ask open-ended questions, which accomplish two things: They promote the flow of information, and they increase the volume of information coming your way. This results in having more information at your disposal, and increases the likelihood you will be able to make a solid working diagnosis and provide quality patient care. By comparison, close-ended questions yield much less information (it's hard to get much conversational movement if your questions all require a yes or no reply). However, for the patient who is in a tripod position, working hard to breathe and, at best, only able to spit out one-, two- or three-word bursts, open-ended questions represent a physiologic nightmare. Listed below are a few suggestions for things you can do to make the most of this assessment challenge.
Think, Then Ask
Take a moment to ask yourself what you absolutely have to know to move forward with your patient care. If the patient has severe dyspnea, you have no choice but to sacrifice the volume of information you'd LIKE to have for the bare- bones information you NEED to have. Make every question meaningful, short and sweet: "Have you already tried your inhaler?" The patient nods yes. "Did it help?" The patient shakes his head no.
Use Multiple Information- Gathering Strategies
When a running dialog isn't a viable communication strategy, you can help your patients by giving them other tools with which to communicate. For example: "Don't talk if you don't have to. Feel free just to nod or shake your head."
Let's say you are trying to administer a breathing treatment to relieve bronchoconstriction. The more the patient talks during treatment, the more that drug vents from the mask, rather than going to the lungs, where it is supposed to go. While the patient is getting the breathing treatment, give him a paper and pencil and have him write short answers to your questions. Not only are you helping him not waste his breath, it's an efficient form of multitasking.
Another breath-saver is the use of hand signals. Have the patient point with one finger to where it hurts rather than trying to put the answer into words. Have him use a thumbs-up or thumbs-down approach to answer your questions: Does your chest still feel tight? Is it getting any easier for you to breathe?
Keep the Lines of Communication Open
Make a concerted effort to keep information flowing to your patient. Let him know up front that you need to gather information and that you realize how hard he is working to breathe. Let him know that you'll try to ask short, to-the-point questions that don't involve lengthy answers. Share with him the communications options discussed above. Don't make him figure them out on his own. The more options you give the patient, the more efficient and continuous the flow of information will be.
Save Their Breath, Not Yours
Don't forget that you aren't the one having trouble breathing. You can help patients save their breath by using yours. Continually encourage your patient to not do anything that increases the work of breathing. Stay focused on the various methods your patient may be using to communicate, lest you miss an important nod or shake.
Make Anxiety Control a Priority
Make certain your patient knows you understand how serious his problem is and that you are going to get it under control. A calm, professional demeanor can have a powerful impact on getting a patient to calm down. With calming comes a reduced heart rate, decreased cardiac oxygen consumption, and overall decreased oxygen supply needs...all big pluses when every breath comes at a premium.
Collectively, using some of the tools above should help you assess and manage these challenging patients more successfully and produce more positive outcomes. Think through your questions and make your small talk yield big results. In the end, your patient will be better for it.
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 EMS Magazine's editorial advisory board.
Mike Smith is a featured speaker at EMS EXPO, October 11-13, in Orlando, FL. For more information, visit www.emsexpo2007.com.