Everyone’s been the new kid at one time or another. The transition from student to new staff member can be challenging to say the least. Here are some tips and techniques that can help you function like an old pro and succeed in your new position.
There are two kinds of EMTs and paramedics: those who have checklists and those who forget stuff. As we increase the complexity of delivering care in the field, with new tools, medications, and approaches to patient assessment, it is easy to forget things. Sensory overload happens to everyone, and the comforting myth of multitasking isn’t rooted in fact. Truth be told, the best among us are rapid task-shifters.
For a rapid task-shifter, checklists, like algorithms, improve patient safety and enhance your ability to deliver consistently excellent care. We have all had that face-palm moment where we forgot something key. Checklists help us avoid those moments.
Even when faced with a situation that doesn’t fit into a protocol or algorithm, making a list of what you have done will help you consolidate your thoughts and organize your next step.
Think about your patient’s status (e.g., complaining of shortness of breath), their reason for calling (“It’s worse than before and not responding to my inhaler!”), your goal for this patient (improve SpO2 to above 94% and decrease work of breathing), and the tools you need to achieve that goal (oxygen, CPAP, SL nitroglycerin).
My initial query to patients used to be, “Why did you call EMS today?” I thought it was an innocuous question. I came to find out it wasn’t. Patients who are sick, especially those with chronic illnesses, feel as if they are burden—to their families, friends, and even EMS. We have all been on EMS assignments where a patient in extremis said to us, “I am sorry to call.” Perception is reality until changed.
I learned to change the dynamic. Those first words make all the difference in how the rest of the patient encounter will proceed. Instead of asking “Why did you call?” I ask, “How can I help you today?” It is a subtle difference that lets the patient know I am there to help—I am there for them. After the patient explains the nature of their problem, I say, “I need to ask you some follow-up questions so I can provide help to you. Is that OK?”
This simple interaction changes the dynamic from what may feel to the patient like an inquisition to that of a dialogue. This lowers barriers between you and the patient and will hopefully improve your ability to acquire the information you require.
The next line of inquiry concerns the patient’s biggest worry or concern. “I’m afraid I’m having a stroke.” “A heart attack.” “I feel like I may die.” This question and the patient’s responses can lead to additional questions and analysis to form a better clinical picture. If you’re thinking the patient is having a gallbladder problem and they say, “I think I may be having a heart attack,” your assessment may include trying to determine if the patient is having cardiac event.
After you complete an assessment of the patient, you can directly address their concern or worry, but most important you can address what you’ll do to help them: “I know you’re afraid you’re having a heart attack, Mrs. O’Brien. Your 12-lead EKG appears normal, but there are other tests they will need to perform at the hospital to make sure you’re not having a heart attack or another problem with your heart. We’re going to give you some oxygen, start an IV, and have you take an aspirin and nitroglycerin. We will continue to check your 12-lead, and we’ll take you to a cardiac receiving hospital so they can do the additional tests you require.” With this you have addressed all her concerns, and she will have greater confidence in you and your team.
If your patient appears depressed, ask them what is wrong. Try to determine if they are considering self-harm or have concern about another person who wishes to harm them. They may tell you they are scared they will die or are having a serious medical issue. Tell them directly, “I am here to help, tell me what you need,” and then do your best to find them help if they are feeling threatened or dispel their fears if they are scared about what will happen next.
You may ferret out some good information a patient has forgotten to communicate. Do they have home health visit? County social services? Did they leave any paperwork? Sometimes we tend to ignore such paperwork, but it can provide a better clinical picture for us. Sometimes even simple questions about nonmedical issues can provide clues.
We were on a call one time, and the patient wanted to refuse assistance. My partner asked the patient about any repairs they’d had on their home recently. The family reported they’d just had a new stove installed in the kitchen. You guessed it: a gas leak.
Avoid terms in your narrative such as physical exam unremarkable or stroke exam negative. If this information is not captured somewhere else in the EHR, describe what you did and found in the narrative. Remember, after you transfer care at the ED, your EHR/PCR will paint the picture of what you found. Using better, more precise descriptions will allow for better communication and result in better care for the patient.
Never say to a patient “I think.” If you are going to start a response off with “I think,” drop that part and just say the rest. Change “I think you are having an asthma attack” to “You are having an asthma attack, so we need to provide some nebulized medications and transport you to the hospital.” You sound more confident not only to the patient but to your peers.
We have so many tools. The most important we carry into the field every day is our brain. The most astute clinicians look for certain physical changes (in trauma) or flex their detective skills to sort through histories (in medical calls), but always be on the hunt for physical components that should guide our decisions.
If a patient has a medical complaint and on the surface it does not appear serious, have an open mind. Do not prejudge, and if this patient is a frequent user of EMS, do not approach the assignment with a preconceived notion about what you think is wrong.
Be diligent and assess the patient. If the patient elects to stay home or refuse care and transport, make sure they have the decision-making capacity to make that choice, voice your concerns, and then provide them with options, but most important tell them what they need to know if their symptoms become more serious and to call back immediately.
If this patient does request EMS to come back, perform a more intensive clinical investigation but do not accept a second refusal—or at least be cautious if you do. Get your medical control physician involved. This patient may have an underlying problem that is either escaping you clinically (it happens to all of us) or difficulty communicating what the exact problem is. If their condition is worse or they’re concerned about what’s wrong, a more in-depth evaluation is probably warranted at the hospital. Convince the patient to seek treatment.
Never approach patient assessment from the standpoint of trying to rule out a condition—our capabilities in this regard are limited. Never employ coercive methods to talk patients out of going to the hospital, either. If your service has a protocol for treat-and-refer, with a clinical guideline, care plan, referral, and assessment parameters, that is different. In those cases we are not talking patients out of receiving care; we are providing them with treatment and resource options appropriate to their clinical condition.
When investigating reproducible chest pain, I think we all make this mistake when we first start out: We approach the patient and ask them where it hurts, and then we press on the area and inquire, “Does it hurt when I press here?” Ugh! There a dozen reasons why it may hurt (for example, you may be pressing too hard with bony fingers!), and possibly none related to why the patient requested EMS.
The better way to phrase this question is, “Does this feel like the same discomfort that caused you to call for help?” or ask the patient if there is anything they do—the way they move or a way they can reproduce the discomfort on their own. Patients will have angina and chest wall pain; the right questions will help you identify the right treatment.
A sudden change in mental status points to a critical patient. When I see a sudden change in mental status in a trauma patient, I ask, Is this worsening TBI? Is this a patient progressing into shock? In a medical patient, again, Is this patient sliding into distributive or cardiogenic shock? Are they having a stroke?
When I look at blood pressure, I always pay attention to whether it is high or low, but I also look at the pulse pressure. A widening pulse pressure could be significant for a patient with rising ICP or even distributive shock due to sepsis.
Narrowing pulse pressure may be indicative of tension pneumothorax, pericardial tamponade, or impending decompensated shock in trauma patients. In medical patients, if the pulse pressure is less than 25 mmHg, it could be indicative of CHF or cardiogenic shock.
When I walk in and see a patient who looks poor in a situation where I would not expect a patient to be hypothermic, I’ll check the temperature of their feet. If their feet are warm, they generally are not in cardiogenic shock. I’ll do this if they have poor skin signs, look poor overall, and have decreased mentation. It is a silly thing, but it tells me whether peripheral perfusion is adequate.
In EMS sepsis is probably one of the more underappreciated calls we respond to. Distributive shock in EMS is the No. 1 type of shock we see in our patients. When we see knee mottling in septic patients, this could be an early sign of microcirculation impairment. We should address this as a critical patient who needs aggressive resuscitation and provide a sepsis alert to the receiving ED.
When monitoring patients being resuscitated in the field, either through fluid administration or vasopressors, utilize basic parameters to determine your success:
Change/improvement in mental status;
Resolution of shortness of breath at rest;
Improvement in hypotension from baseline.
The quick method to determine the effectiveness of fluid resuscitation is to utilize dynamic parameters such as radial pulse (absent or present, weak or strong), mental status, skin temperature, and capillary refill time to determine the patient’s response.
The most important tool we have is our brain. Words matter, and in that first patient engagement we have a tremendous impact on how the rest of an EMS assignment will proceed. Think about what you say and write. Regardless of the emergency, we always have about 30 seconds to size things up and make a move forward. Simple assessment parameters will tell us a lot about our patient.
Daniel R. Gerard, MS, RN, NRP, is EMS coordinator for Alameda, Calif. He is a recognized expert in EMS system delivery and design, EMS/health-service integration, and service delivery models for out-of-hospital care.