Clinical Decision Making in Patient Assessment

Part One: LOCATE the Patient

This is the first installment of a three-part series on patient asse3ssment. Part one will introduce LOCATE system as a guide to help the EMS provider on assessing the patient, the scene, and as a decision making aid. Part two will discuss the not-so-obvious details of physical exam finding, and in part three; we’ll discuss assessment aids such as the Cincinnati Stroke Scale, Pediatric Assessment Triangle, and trauma triage schemes.

It seems simple enough; before you can provide treatment and transportation you have to find the person in need of your service. Actually finding the patient is only part of the job. Providers of emergency medical service (EMS) at all levels must prepare themselves prior to reaching the scene or patient for a variety of potential actions and outcomes. Waiting to arrive on-scene to develop a care plan or mental review of the potential scenarios places both provider and patient at a disadvantage. The fire services use the process of pre-incident planning and size-up to prepare firefighters for potential needs or dangers of any given situation. Pre-incident planning can be used to anticipate additional resources and special needs of a situation. Emergency medical services can and should do the same.

EMS and fire service text are filled with acronyms that have become part of daily conversation. Acronyms are memory aids that range from the simple ABCDE’s that remind us of the basics of patient assessment to SLUDGE as a memory jog for organo-phosphate exposure symptoms. In this installment we will introduce the acronym LOCATE as a means of assessing not only the patient, but the scene and patient needs as a whole.

Location. In the real estate business location is everything and so it is for EMS. What do we as EMS providers need to know about the location we are responding to in order to accomplish our goals and objectives? What can we tell about a situation before we enter the environment? Let’s consider the following questions:
What type of occupancy are we at?
How well do you know your response district?
What geographical special needs or special hazards have to be considered?

Respocnes to group homes, rehabilitation centers, and senior living centers demand special attention by the responder. The structure itself can yield important clues as to the special needs of those inside and impact your options. Calls to medical facilities and clinics add yet another dimension to your response such as dealing with medical professionals and therapy-in-progress. The key to situational assessment is to anticipate, not stereotype.

Obstacles such as ramps, lifts and the presence of customized vehicles should prepare you for the special needs of the person inside the location and warn you about special hazards of getting in and out with all your equipment (including your lumbar spine) safe and intact. Commercial buildings and public places offer some challenges that are not as obvious. Small elevators may prevent your crew from arriving or returning together. Who will stay with the patient and what vital equipment will you keep with you? In public places on-lookers can become an obstacle. Patient dignity and privacy in the public venue must be addressed differently than in a private residence in effort to preserve the comfort and cooperation of the patient during treatment. The responder must also consider the presence of security video surveillance, camera phones, and other digital recorders. Responders must anticipate that a majority of the public owns some type of digital recording device and consider the impact these devices may have on privacy and care.

Conditions such as post medical conditions are a routine part of EMS assessment. Now consider the living conditions you find the patient in. By being observant to living conditions; EMS providers have a unique opportunity not available to others in the health care system. Situational awareness can yield important clues that must be relayed and addressed by the health care system. The GEMS diamond used in Geriatric Education for Emergency Medical Services is a good example. The EMS provider must again ask themselves a number of questions:
Are the patient, the family, and the care givers able to carry our daily activities?
Has there been a change in how the patient cares for themselves? If so, is the cause of the change medical in nature, such as in the setting of CVA/TIA, or social a aspect such as the loss of a spouse or other supporting person?
Family support or lack thereof plays an important role in every situation. The EMS provider must not only find medications but assess if the patient is physically and mentally able to take them.

The presence or absence of Accessories is closely related to conditions and considers physical items.
Is the patient using the cane or walker? If not, is lack of use or lack of the device a cause of falls and injuries?
Has the patients’ ability to use such a device changed and are they no longer able to use their accessories?
Other accessories that should be assessed include home oxygen units, air-powered nebulizers, ventilators, hospital beds and lifts, commodes, and orthopedic devices. The presence of basic medical supplies can also indicate the level of care a person should receive on a daily basis. The presence of many other medical accessories may also indicate the need for another and arguably more important need; and educated caregiver in the home. There is no substitute for the love and compassion provided by a family in the home-care situation. EMS providers must harness the educated family or caregiver as a precious piece of the assessment puzzle. Failure to do so can result in the loss of valuable information, inaccurate diagnosis and treatment, and poor public relations.

Treatment is what you do for the patient. Your assessment should lead to a working diagnosis list and guide your treatment. Treatment provided by previous EMS responses and discharge paperwork from previous emergency department visits is also important. We all have a list of frequent users of our services but, do we communicate what we’ve done to help these people? We shouldn’t have to reinvent treatment each time we see a previously treated patient. Multiple requests for “lift assists” for example, may indicate subtle changes in patient condition or change in social status indicating the need for augmented services. The key is to anticipate, not stereotype.

Evaluate the need for Education and Extra help. The EMS provider has the ability to see the patient in their surroundings as they are every day. EMS should also be knowledgeable of patient education topics pertaining to safety and well-being, social programs, and signs of abuse. Consider the following questions:
Are you aware of the signs of elder, child, or domestic abuse? If so, what are your reporting requirements?
Are you aware of the community programs that may be of benefit to those in crisis?
Being able to provide information on social programs and domestic support are vital for the EMS provider.
Evaluation must begin prior to response. Weather conditions and time of day must also play a role here. Other events; natural disasters and intentional events locally, nationally, and internationally must also be taken into account. It is here that you have the opportunity to help any member of the public prepare for crisis…even those that are not medically related.

Summary
The ability to assess the scene and the patient before you arrive is a skill learned with experience. The acronym LOCATE is:
Location
Obstacles
Conditions
Accessories
Treatment
Evaluate, Educate, Extra help
Use LOCATE to guide your patient care plans on-route, on-scene, and after care to build your assessment of the patient as whole. Pre-planning and size-up are important aspects of patient care; if you LOCATE each patient you will be better able to keep these points and patient care in focus.

Clinical Decision Making

The following is an excerpt from my Clinical Decision Making lecture series on cardiac emergencies. In this selection I focus on the “nuts and bolts” of chest pain and congestive heart failure. The continuation module; SYNCOPE: The EMS Fatal Masquerade will be published shortly.

Previous Clinical Decision Making lectures include LOCATE the Patient and The Dead: Clinical Decision Making in Cardiac Arrest. The latter are under revision and will be re-issued in January 2006.

Cardiac Events and Congestive Heart Failure
It comes as no surprise to the experienced EMT or paramedic that a majority of patients requesting emergency medical service have complaints of cardiac or respiratory nature. These complaints are often categorized from the acute complaint of chest pain, syncope (or near-syncope), or short of breath to cardiac arrest. Most often, when someone calls EMS, there is little question as to what the problem is…especially when the chief complaint is stated as above. Difficulties arise when the chief complaint is less evident and patient presentation is less than acute as in the case of the “weak and dizzy”, the elder person who is just “not acting normal”, and the cold/flu patient.

The difficulty is for the provider to differentiate between the two and treat appropriately. Making the call between myocardial infarction, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and cold/flu can be difficult in any setting. Mistaking the patient in CHF for one who has respiratory infection can be deadly. Equally so, is the patient with syncope or near-syncope that claims to be “fine” now. Conducting a through assessment is critical to discovering what type of condition the patient may have, formulating a differential diagnosis list, and making treatment/transport decisions.

Chest Pain
Discovering the etiology or cause of chest pain can be difficult for EMS providers mainly because the pain is described in vague terms. Patients with cardiac related pain or discomfort often have visceral pain. A patient with visceral pain may complain that the symptoms are located in a general area and intermittent yet, worsen with time. They also note the nature of the pain as dull, aching, or numbness. By contrast, somatic pain is able to be localized to a specific area by the patient. This somatic pain may change with movement or position of the patient. A word of caution is due here; any pain in the chest, either somatic or visceral, must be taken seriously as a potential cardiac event. Fundamental BLS care including oxygen and evaluation by advanced life support is necessary.
In addition to the quality (visceral or somatic) of pain, the location of chest pain is also non-diagnostic. That is; the location of pain often will not directly relate to the origin of the pain. Many groups of patients may not experience the “classic” symptoms of chest pain, shortness of breath (SOB), arm/neck pain, nausea, diaphoresis, and the like. Diabetics, elderly, and post-menopausal women may experience altered or atypical presentation of a cardiac event. Persons who are chronic drug abusers may also not report textbook symptoms. In any case, decreased severity or absence of pain does not equate to a non-life threatening condition in the setting of chest pain. In addition to the classic signs and symptoms of cardiac events, be on the lookout for the following list in addition to the classic symptoms:
· Weakness and fatigue
· Pressure in the chest
· Palpitations, or racing heart
· SOB or dypsnea…even if mild
· Painful digestion, dydpepsia
· Neck, back and epigastric pain
· Symptoms that wake the patient from sleep or keep them from sleeping
· Any change in mental status, syncope or near-syncope…even if the patient “is fine now”.

Any one of the above should indicate potential for a cardiac event, with or without chest pain. With these complaints, the EMT must consider acute myocardial infraction (AMI), angina (stable and unstable), cardiac dysrhythmias, and pulmonary embolism. Again, solid BLS care should be initiated as well as ALS assessment and transport.

Congestive Heart Failure
Congestive heart failure or CHF is a situation when one or both (univentricular and biventricular) of the heart ventricles is no longer capable of maintaining discharge capacity of fluid returning to the heart. The results may be seen in the form of any number of symptoms depending upon what side of the heart is failing.

This is a good time to remember some basic physiology of the heart. The right side of the heart is under low pressure in relation to the left heart as it receives blood from the body (pre-load) and is responsible for pumping into the pulmonary system for gas exchange. With this in mind, one can visualize that any factor the restricts or diminishes the right heart ability to push blood will result in a backup of fluid into the systemic circulation; the liver and dependant areas for example. This situation is compounded by inability to get blood to the pulmonary system for oxygenation. When this occurs, not only is oxygenation impaired with resulting hypoxemia, but the left ventricle (and cardiac output) also becomes challenged. Simply put, the left heart cannot pump required volume if that volume is not delivered (no pre-load, no after-load). These situations can arise from AMI, valve failure (tricuspid, pulmonary, or both), and fluid depletion. Paradoxically, the most common cause of right heart failure is left heart failure a.k.a Cor Pulmonale.

A similar situation occurs if the left or high pressure side of the heart is involved. The left heart can be thought of as the high pressure side and is responsible for ejecting blood to the body via the aortic valve and the aorta. This is known as after-load. Anything that reduces the left ventricles efficiency can technically cause left heart failure. Think of it this way:
If volume entering the left atria are insufficient, there will be decreased discharge
If the mitral (bicuspid) valve fails either by stenosis or regurgitation (narrowing or allowing backward flow), the left ventricle (LV) either cannot fill or losses discharge pressure and volume back to the left atria.
If the aortic valve is stenosed or narrowed, the LV must work harder to discharge the needed volume and pressure.
If the LV is damaged from AMI and not able to accommodate the preload being sent

These bullets indicate that LV failure can come from any number of causes: AMI, valve failure, and prolonged high systemic pressures (high blood pressure). Regardless of the cause, the results of decreased cardiac output and backup into the pulmonary system (high pulmonary pressures and pulmonary edema) may be seen.

Common Sense Stuff
Heart failure is basically a theory of backed-up fluid that accumulates behind the chamber (or side) of the heart that is affected. Patients with severe left ventricular infarction often exhibit symptoms of respiratory distress and hypoxia as a result of impaired pumping ability (decreased after load) and pulmonary edema as the existing pre load backs up behind the left ventricle. The increased pulmonary pressure is passed on the right ventricle and may eventually cause it to become impaired. In the setting of right heart failure, either resulting from left heart failure or right ventricular AMI, pre load decreases (remember: the left heart can’t pump out what it doesn’t get) and fluid backs up behind the right heart and into the systemic circulation. This fluid accumulation becomes visible as ankle edema, edema in dependant areas of the body, and liver engorgement (congestive hepatomegaly).

Is It Acute or Chronic?
We may find any number of symptoms of heart failure presented to the EMS provider. Unfortunately, the early or mild symptoms may be confused for cold/flu symptoms…a dangerous clinical assessment mistake! The symptoms depend not only on the side of the heart affected, but the rate at which pathology develops. Look at it this way; if a patient suffers a massive MI, arrhythmia such as rapid atrial fibrillation/ventricular tachycardia, or valve failure, drastic reduction of cardiac output and/or pulmonary edema may follow. If the patient goes on to survive any of the above or if conditions progress over a long period of time, the patient may compensate. Compensatory mechanisms may include enlargement of the heart, and many form of neurohormonal changes. In this case frequency of EMS contact and ED visits often increased.

Review of HHS Pandemic Flu Plan

I've wallowed in the 394 pages of the HHS Pandemic Influenza Plan for the last day or so.

I've wasted my time.

The goal was to review the plan, come up with workable solutions and methods to put the plan into practice...everyday use. You know, that "All-Hazards" stuff I keep talking about.

A number of healthcare and allied healthcare groups have come out swinging against the Plan. Although I will not take such an extreme view, I would describe the plan as non-workable. The little voice keeps asking me "after the Anthrax attacks of 2001 and all the WMD training we've done; why don't we have this plan workable and ready to go now?" Another reason why all the "terrorism" and "WMD" training has been a waste...the EXACT same actions, materials, and protective measures employed against a biological intentional event could be used in the setting of a natural event...The flu. See the posting Its Time To Stop Training for Terrorist and WMD Events for my full rant on this.

Here is the problem(s): HHS estimates that the H5N1 avian flu could kill 1.9 million Americans and hospitalize another 10 million. This is based on the potential of the virus to spread rapidly world-wide, people being infectious and asymptomatic, simultaneous outbreaks, and demands on the health care system. Of similar concern is the potenial disruption of infrastructure including public safety due to widespread illness and death among workers and concern about on-going exposure to the virus. Yet, the Plan fails to identify any actionable precautions outside of standard body substance isolation and respiratory etiquette. The Plan also makes note of the Strategic National Stockpile (SNS), yet today, long after 9-1-1, few cities have the abilities or even the plans in place to receive and distribute the SNS. The Plan also calls on non-traditional and traditional responders, emergency and domestic support groups to all work together under the Federal Response Plan and the National Incident Management System (NIMS). The fact, again, is that..well let me ask you; do you know your role in NIMS or duties under the FRP? Chances are you don't. See the problem?

The good news is that we've been doing BSI/PPE and respiratory etiquette for a long, long time. The bad news is that we've failed to learn from the hysteria of "white powder" events and the SARS epidemic.

The bottom line:

1. Wear a mask-N95 if you've got it, but wear a mask
2. Put a mask on the patient- over the cannula or non-rebreather
3. Cover your mouth when you cough or sneeze
4. Wash your hands...and do it often
5. Put all the Bio-Terror training into play in the event of any natural flu outbreak
6. Don't bother reading the Pandemic Influenza Plan...It's a colossal waste of paper

Stop training for terrorist and WMD events!

Its time to stop training for terrorism and weapons of mass destruction!

Our language reflects how we think and act. When we place a term on an issue, that term becomes face or imprint in our mind for that given issue. Terrorism and weapons of mass destruction (WMD) are two terms arisen out of the September 11, 2001 attacks that have been imprinted on us. Although not entirely new terms for many in the traditional response group of emergency medical service (EMS), fire service, and law enforcement; terrorism and WMD became the language defining events of National crisis. These and several other terms have taken on a center stage appearance since 9-1-1. Highly paid “experts” have become obligatory content in any number of trade journals and conferences. Emergency service organizations have received millions of grant dollars to purchase training/education, equipment, and supply all to be brought to defend against terrorism/WMD. That is the good news.

The bad news is that most of the training that has been conducted is next to meaningless. Before anyone starts typing a response – four letters at a time – let me explain. A majority of the training conducted is next to meaningless because it lacks context to what is encountered and managed every day. That is to say; we need to take the all-hazards approach to training and relate the material to the bread-and-butter jobs paramedics, EMT’s and firefighters respond to. Doing so will keep the skills and knowledge fresh and usable. If we continue to wrap this material up and say “don’t open ‘till terrorist attack” we will not be able to use it properly. We must take the message given by intentional event training and project it across routine, every day events. I believe the terms terrorism and WMD should be replaced with intentional events.

A good example would be to apply the all-hazards approach to triage. Ask any group of emergency medical technicians or firefighters, veterans or rookies, if they’ve ever worked an event that they’ve needed to do triage. You might get one or two that have, but the majority will claim to have never needed their triage skills. In reality we all have. The fact is that we do triage on each and every call we’re on. Triage means to sort and prioritize. We do that with every patient, looking at injuries and complaints, making decisions about what to treat first and how. Firefighters triage the situation, the building and the fire…only it’s called size-up, and we’ve been doing it for years. Educators who can describe intentional event preparedness in this format will be giving the student the tools to truly be prepared.

I’ve found numerous training officers (you know, those supposedly setting the example) who would come to me after a lecture and buoyantly declare “this WMD stuff is all well and good, but my guys need to get back to basics”. I usually ask those officers if they believe the “basics” include training on poisons and toxics like organophosphate materials. Or, might we be able to find time in our zealous training schedule to include basics of mass casualty management. Oh, the irony of it all! For these same training officers do not hesitate to defend the need for hazardous materials or mass casualty training yet miss the more than obvious relationship between intentional events and the hazardous materials event or bus crash. I guess if we call it haz-mat they’re OK with it, but; terrorism…hell, terrorism can’t happen here, right? Not to mention the probability of a natural event impacting any community.

The point here is this; we have to blend what we’ve come to know as terrorism/WMD training into the “basics” of EMS and fire service. To do so is simple because of the similarities between the intentional (terrorist/WMD) event and haz-mat accidents, mass casualty events, and natural disasters.

Here’s a quiz: What do accidents, man-made events (human initiated to be politically correct), and natural disasters (ice storms, hurricanes, earth quakes, floods) have in common? Here is short list of examples:
Little or no warning
potential for large numbers of civilians needing assistance
multiple casualties and fatalities
protracted operations
limited resources

The all-hazards approach looks at preparing us for a multitude of potentials. Not everyone has to be ready for a blizzard or a wildland fire, but we should all be cognizant of the need for self-protection, working within the incident management systems, triage and the like. We also must take advantage of our existing knowledge and skill base by putting them to use in the context of terrorism/WMD events.

The labels of terrorism and WMD may have been a great disservice to our responders and citizens. Those terms imply an event that most people don’t believe will ever happen to them. However, the principles, tactics, and added knowledge that training for intentional events advocate can traverse a multitude of disciplines and events.

Let’s try to change our thinking.

In the following posts we’ll begin to address the all-hazards approach in greater detail. Look for EMS case studies and situational reviews as well.

Opening Day

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Key Words: Fire Department, Emergency Medical Service, EMS, Disaster, Terrorism, WMD