Assessment skills are everything in medicine. You’re ability to operate in an advanced care environment is almost entirely dependent upon your ability to properly assess your patient. Yet so many paramedics give assessment but a passing thought. Too much focus is given to treatment, when your treatment strategy is based entirely on assessments! Stop the insanity! (…anyone?…early 90’s pop culture reference?…ugh, I’m old) Â Most paramedics can regurgitate the four end-points of Procainamide administration but so manyÂ struggle with walking into a room and efficiently/effectively assessing a patient’s complaints.
Assessment is as much an art form as it is a science. It’s as much psychology as it is medicine. Knowing how to tailor an assessment to a specific patient and unique set of complaints, takes a skillful provider. Admittedly this skill is honed with experience. Much of this process can’t be trained as much as it is experienced. But the sooner we allÂ realize that the way that many of us have been taught to perform an assessment, through a rigid algorithmic process, isn’t the way to properly go about assessing the patient, the better off we will become at this skill. Here are a few tips for improving your assessment technique.
Â Â Â 1.Preemptively engage your brain.
We’re all taught this in the education pipeline. Think about what you might encounter on the way to the call. But this is something that gets lost in the shuffle for most providers. They are focused on managing radio comms and getting safely through traffic. Which are two extremely important things, yes? But we all well know most calls lend us the opportunity to start forming a differential diagnosis based off of the info given in the dispatch.
Now, trust me, I know that the dispatch info doesn’t always match the patient we encounter. Key in, however, on the descriptive parts of the dispatch. For instance, if the complaint is chest pain are there any additional descriptors in the dispatch that might guide your differential. Is there nausea, dyspnea, syncope? Did the dispatch indicate a cough, fever, chills? Did the patient get kicked in the chest by a mule?! With each of theseÂ symptomatologies, you can more clearly define a differential Dx and prepare yourself for the patient you might encounter. Additionally, you can mentally run through treatment strategies, possibly refreshing your memory toÂ something forgotten, a drug, an intervention technique, before you ever get to your patient.
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Â Â Â 2.Really, actually, truly..no kidding.. form a general impression.
Remember that part of the assessment? The ole’ general impression. Otherwise known as the most often forgotten paramedic assessment tool? I can’t remember how many times while debriefing a call I’ve asked someone their general impression of a patient and immediately their eyes gloss over. They never actually formed one. They just barrel into the scene, drug box and cardiac monitor in hand, ready to dispose of disease. And I’m not just talking about new people. This is seasoned providers as well…myself included! We all forget to use the power of the general impression.
Take a moment. When you walk into the room, or arrive on the scene. Just take an extra moment and look, listen, smell. Use the senses you were given (I wouldn’t use taste here…). Form that “sick or not sick” first impression. That simple act of actually forming a general impression will guide the treatment you provide. If your patient presents in profound medical distress, “sick,” you immediately shift into gear to support any derangement in the ABCs. You may never get past this point with critically ill/injured patients. You may spend the entirety of that call supporting the basic components of life. And that’s ok. That’s what we do well!
Most frequently however, your patient isn’t in manifest distress. It’s with these patients that our general impression is actually more useful. How do all of these clues come together to paint a picture of her patient’s current condition? How are they sitting? How are they speaking? Do they appear to be in discomfort? What does their skin condition look like? What are the environmental and scene conditions? Specifically taking the time to form this general impression will often give you the information to shape your continuing assessment. It will certainly prepare you to transition to a focus on specific complaints as they arise.
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Â Â Â 3.Talk (and listen) to your patient.
Conversation, ain’t it grand? You’ll know when you’re assessment skills are getting sharp, when you can obtain all the information you need from your patient by just having a conversation. My advice to you, stop sounding like a robot. Those acronyms (SAMPLE, OPQRST, etc..) are great. They give you a framework to guide your assessments. But they shouldn’t be used as a script for every patient interaction. “Excuse me ma’am, when was the onset of your pain? Is there anything that palliates or provocates your pain? How would you describe the quality of your pain?…” Meanwhile your patient is staring at you like an automaton. Just talk to your patient. Like a human being. Like you would want somebody to speak to you. You can still ask all of the important questions, but asked them in the context of a simple conversation. Obviously this requires a talking patient. I would venture a guess that, fortunately, the majority of your patients are talking.
Also listen to your patients. I see too many medics ask questions but theyâ€™re not actually processing the information the patients are giving. Listen not only to what your patients are telling you, butÂ how theyâ€™re telling you that information. So much information can be gleaned from subtle contextual clues in how your patient is speaking. How many times have you listened to a patient tell you that they didn’t have any pain, however something about their nonverbal communication indicated distress? Many times in I have found while assessing a patient, all the physiological parameters checked out just fine, but I could tell by the way they were communicating with me that something wasn’t right. Take the extra time to actually listen, and listen intently, to your patient.
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Â Â Â 4. Stop thinking like a paramedic.
Huh?Â Yup. Take a minute and stop thinking like a paramedic. Stop thinking about rigid protocols. Stop thinking about all the acronyms and the formulaic thinking you’ve learned. And instead, start thinking like a physician would. That’s right, play doctor for a moment. Don’t try to fit your patient into a narrowly defined protocol. So often because our scope of practice is limited we try to fit our patients to the treatments we have available. Instead, assess your patient as if you had the totality of medicine at your disposal. Form a differential diagnosis and then a working diagnosis(…yes…get over it…we diagnose…it’s just a word) without consideration of your protocols. Then consider what should be done for this patient. You may or may not have the needed intervention at your disposal. This is the point you’re going to have to consider protocols and the interventions available to you and within your scope of practice. Yes, you’ll be back to fitting your patient into these protocols. But you will have reached this point by performing the an objective assessment. Your patient will be better prepared for hand-off and the continuum of care. And more importantly your treatment will be based off your patient’s condition, not a compulsion to fit them into a protocol.
Â Â Â 5. Slow down.
What your Â hurry? Your lunch will still be there when the call is over. Cold…. a little soggy…. but still there. Seriously. You’ve heard the saying, “slow is smooth, smooth is fast.” There are very few calls in our world were time is truly of the essence. Major trauma, cardiac events (STEMI, in particular), and neurological emergencies. When it comes to prehospital medicine and rapid transport, these are just about the only things that have been proven to have time sensitive morbidity and mortality. If you find yourself with a patient and any of those complaints, expeditious assessment transport is indicated. However, on the other 98.73% of the calls, slow your roll. I guarantee you we all have missed important information on assessment because we were in a hurry. Lord knows I have. But when I stop and remind myself that I have all the time in the world that I need to complete this assessment, I find I pick up on things I might have otherwise missed.
Assessment is truly an art form. It’s something that each of us that call this a career should work to be better at with every patient contact. Regardless of your experience level, your assessments can improve by simply focusing on a few of these points. Understand that rigid thinking is for the weak minded. We have to get away from being protocol monkeys. We have to raise our level of competency (Check out this post). And our assessment skills are at the top of that list.
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