# Poor Historians: Asking the Right Questions?



## TKO (Apr 15, 2008)

I consider myself a pretty good communicator; gooder than many other peeps I know anyway.

But lately I've been running up against a lot of poor historians and ramblers in my community that can really frustrate me, say when I'm code 3 for chest pain, already 20 minutes on-scene, and trying to find the proper course of treatment by way of protocol and the pt is telling me about some pain in their leg they had in '67.

This isn't uncommon for most of us.  However, one partner of mine said that he was being grilled by an ED one day and he told the doc that the pt. was a poor historian.  The dr then told him (quite fairly, too) that for all of the medical knowledge we are taught, the one thing that isn't and should be, is how to properly ask the right questions.  That this far too uncommon skill could be passed on from doctor to doctor but rarely beyond that.

So now I wonder if any of you have any solid tips for communicating with the difficult pts when you are under pressure of time or whatever.  I thought I would ask here because I figured for sure that Rid and a few others would have a plethora of gold nuggets to offer me.


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## Hastings (Apr 15, 2008)

It is possible to be polite and assertive at the same time. If they get off track, politely tell them that you're most concerned about the CC and would like to know more about it. Ask direct questions, though try to keep them open-ended (not yes/no).

However, if the patient really is a hopeless historian, it is okay to ask yes/no questions in order to get the minimal amount of information.

Just be specific. That's all.

Rarely have I had a patient ramble on with direct questions such as:

1. Can you rate your pain on a scale of 0-10, 0 being no pain, and 10 being the worst pain you've ever felt?
2. Can you describe the pain?
3. Can you point to where it hurts?
4. Does it radiate anywhere?
5. What were you doing when the pain started?
6. Are you having any difficulty breathing? (I know, I know, it's a yes/no question. Which is why you follow it up with...)
7. How would you rate the difficulty breathing on a scale of 0-10, 0 being no trouble breathing, and 10 being unable to breathe at all?
8. How long has the pain you have now been going on?
9. Does it feel any different when you sit down or rest?
10. Has it gotten better or worse?
11: Have you had (insert specific body system here) problems before? [heart, breathing, etc; NEVER pain in general]
12. Are you allergic to any medications/bees/food? (Be specific, don't cut it off at 'allergic')
13. Are you taking any medications?/Do you have a list of your medications?
14. Have you been taking your medications regularly?
15. Have you had any surgeries or medical procedures in the last year? (Or ask about specific procedures. In a cardiac call, ask about procedures done on the heart.)

Types of questions to ask carefully:

1. Have you ever felt this way before?

Types of questions not to ask:

1. Do you have any other medical problems I should know about?



If you ask questions in the OPQRST and SAMPLE formats as is - I assume - widely taught, there is no reason you shouldn't have the vital information within 2 minutes, max. Don't be afraid to cut the patient off and keep them on track.


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## Jango (Apr 15, 2008)

Good info!!!  I have already made a cheat card(idiot card) to help me remember those!


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## Ridryder911 (Apr 15, 2008)

History & physical (H & P) is an art form. It improves with experience. One has to be in control and focus the questions in regards of the history, making sure not to cut off or exclude potential insight to assist in the diagnosis. 

As described, closed ended questions will not get or be able to obtain the needed information. 

R/r 911


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## BossyCow (Apr 15, 2008)

I think too that we need to remember that while its polite to listen to our elders and treat them with respect, gently interupting a story and reminding them of the question you originally asked is acceptable. What we are having with them is not a conversation, although it is conversational. Next time you are at the doctors office or in the ED while a physician is in the room, listen to the way they interview the pt.


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## Ops Paramedic (Apr 16, 2008)

As said before...History taking is an important skill that can be aquired, with practice and consulting history & eximination texts.  Be carefull to just look and listen to the way that some practitioners perform history taking, as you may pick their bad habbits.  There are some of the pnemonics that can be used on the majority of the patients, that only covers the basics, but will surfice.  However every patient is unique, and you should adapt your history taking method as such.  Communication involves you making use of all your senses, and oberserving the actions of the patient as a whole.

I understand how you feel with regards to your patient being the historian, they can carry on & on & on... Yes you have to get the history you require and may feel that what the patient saying is irrelevant, but it is not always about you listening to what the patient has to say, but rather the fact that you are listening (Build the relationship between you and the patient), etc..

As for your patient, hypotheticaly speaking,the leg pain may leed you to your diagnosis, or cause of chest pain.  Lets say this pain in his leg, many years ago, resulted in some form of surgery on the leg.  What should the next thought be??  Lets investigate the possibility of a pulmonary embolis, and rule it out as differential diagnosis...

Good luck!


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## paramedix (Apr 16, 2008)

Talk, talk, talk... you can learn so much from your patient and his current condition by just having a discussion. 

I am a great fan of obtaining social history and surroundings. The stuff that came to light was of great value towards the prov. diagnosis and would not have been picked up from the standard acronyms.

If you see something, ask. You smell something, ask.

Adapt your own system and teach to others, dont let bad habits sink into yours. Good luck...


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## CFRBryan347768 (Apr 16, 2008)

i like asking the same question 5 or 6 diffrent ways


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## Hastings (Apr 17, 2008)

CFRBryan347768 said:


> i like asking the same question 5 or 6 diffrent ways



Seriously?

I've always found it to annoy the patient and waste time. Although, asking the same question a different way if you don't get a straight answer would be reasonable in most situations. Maybe they didn't understand.


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## BossyCow (Apr 17, 2008)

Hastings said:


> Seriously?
> 
> I've always found it to annoy the patient and waste time. Although, asking the same question a different way if you don't get a straight answer would be reasonable in most situations. Maybe they didn't understand.



I don't think its a matter of the answer being 'straight' or the pt understanding. We are looking for specific information. The pt is in pain, discomfort, scared, and totally unfamiliar (with few exceptions) of the emergency process. Some pts just can't differentiate between what you need to know and what they want to tell you. 

I do ask the same question several different ways, When did this start? So you ate breakfast first and then it started hurting or was it before? And this has been going on how long now? You can walk the pt through the process to get from "Some time this morning" to "I know it was after breakfast and I was watching the local morning news so it had to be 9:15 or so" Besides, I have a a long transport so I got nothin' better to do!  

A good reason for this is being walked through the timeline helps the pt think about what they are telling you and get clearer on the details. It also avoids that unpleasant surprise when they are talking to the RN in the ER and suddenly remember that they did have this once before and it was a gall bladder attack and the doc said they should probably have it out but they didn't have time and it got better


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## Hastings (Apr 17, 2008)

BossyCow said:


> I don't think its a matter of the answer being 'straight' or the pt understanding. We are looking for specific information. The pt is in pain, discomfort, scared, and totally unfamiliar (with few exceptions) of the emergency process. Some pts just can't differentiate between what you need to know and what they want to tell you.
> 
> I do ask the same question several different ways, When did this start? So you ate breakfast first and then it started hurting or was it before? And this has been going on how long now? You can walk the pt through the process to get from "Some time this morning" to "I know it was after breakfast and I was watching the local morning news so it had to be 9:15 or so" Besides, I have a a long transport so I got nothin' better to do!
> 
> A good reason for this is being walked through the timeline helps the pt think about what they are telling you and get clearer on the details. It also avoids that unpleasant surprise when they are talking to the RN in the ER and suddenly remember that they did have this once before and it was a gall bladder attack and the doc said they should probably have it out but they didn't have time and it got better



I'm afraid I still have to disagree.

As a paramedic, I don't have the luxury of time. I'm going to ask once, repeat the answer once for confirmation, and move on to the next question. Not only does asking numerous times/ways irritate the patient, but if I get an answer, it's going to be a close estimate, and I don't need to be within 5 minutes of the exact time in order to form a 'diagnosis' and treatment plan. You're right, the RN will probably get more accurate information. Will you get ridiculed for not being within the hour? Absolutely not.


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## TKO (Apr 18, 2008)

Thanks to everyone for their contributions.  I should have been more specific for some that the questions that I ask in obtaining a Hx isn't problematic, it is the method in which some or many of us ask them, and that is where I am wondering if anyone has suggestions on better methods of communication.  IE: some elders require respect or they won't give you squat.

And many of you stepped up and gave some good tips.

But the problem remains that outside of paying more time to the doctors and how they communicate with the pts, that it is still difficult to communicate with pts because we often in their home turf and are under the pressure of time that once they are in-hospital doesn't exist the same way, and if it does, the nurses are going to tear us new ones if we don't have needed info for them.

It is terribly frustrating to get these elderly pts to describe their PHx and OPQRST in a relevant and focused manner (the pt I was talking about above was more interested in talking about herself and family than she was about her chest pain).  I spent 3 minutes on trying to determine her pain scale, with references from 1 to 10 and then none-some-bad-worst and other analagies before she thought for a moment and said she didn't understand what I was asking her.  Then I gave up on that question.

My U/C knew of her upon looking at my run sheet and ROTF'd because she said it was amazing I got as much out of her as I did.  Our town has a number of very poor historians that really just want to go to the hospital and have a conversation with us along the way.  

I suppose they just remember the old ways and paramedics and nurses were just support staff to the allmighty doctors of their day and they just don't think that the questions we are asking them are as important as the questions the doctors are going to ask them.

My U/C had a good pointer: if you can't talk to your pt, then get the meds together and see what they are for.  That'll help determine their pertinent Hx.

But you know, if one of you know of a really good nerve in the ear to pinch that forces pts to focus on every word we are saying or a vulcan mind meld trick that allows us to share one mind, well that will be perfect for all intents and purposes!  Otherwise, asking questions and maintaining eye contact during their answers or something is great advice too.


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## BossyCow (Apr 18, 2008)

Hastings said:


> I'm afraid I still have to disagree.
> 
> As a paramedic, I don't have the luxury of time. I'm going to ask once, repeat the answer once for confirmation, and move on to the next question. Not only does asking numerous times/ways irritate the patient, but if I get an answer, it's going to be a close estimate, and I don't need to be within 5 minutes of the exact time in order to form a 'diagnosis' and treatment plan. You're right, the RN will probably get more accurate information. Will you get ridiculed for not being within the hour? Absolutely not.



Hmmm I've worked with a lot of medics and I haven't seen a pt get irritated at being asked questions. If done properly and conversationally it doesn't need to be an interrogation. As a paramedic, you do have the responsibility to accurately interview your patient, and since some patients are less socially skilled than others, does your 'efficiency' override your responsibility to fully assess a pt's condition and get an accurate history?

I'm not saying that every pt needs the numerous questions, but the post was about the difficult pt. The rambling old lady who hasn't had people in her home much since her hubby died. Not being able to take the 'luxury' of spending time with her may negatively impact your ability to assess her condition.


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## emtwacker710 (May 21, 2008)

something you could try is the wording of your questions, word them so that the pt. will have a hard time bringing something else up, (short, sweet and to the point) but also if you do have the time, to make the pt. feel more comfortable have them talk about the "other stuff" while you are doing the paperwork en route to the ECC. I've done it a lot with some of the older pt.'s I especially like talking to the war veterans if I have the time..it really makes their days..


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## mrhunt (Jan 13, 2022)

something ive learned with poor historians as well...Often times the mechanism is obvious but the Pt will get "stuck" insisting that isnt the case and the assessment hits a dead end.  Basically i have to use terminology the Pt will "accept" if its true or not. Case in point: 

Just had an elderly woman who was on the ground right next to her bed. She stated she went to stand up, couldnt and wound up on the ground and now has Left Rib pain.   When i stated "is this rib pain NEW, after your fall tonight?"  The pt wouldnt answer the question , but instead continually stated that she DIDNT fall.   (she didnt sit on the ground, intentionally lay on the ground or roll out of bed and even so thats still a fall in its own right)

SO to get around this i stated "did the rib pain start BEFORE or AFTER you wound up on the ground?" 

It works.  

Unfortunately this lady was terrible still and told me after, but then told the hospital its been going on for months now.  but still, it let the assessment proceed somewhat. 

Holy **** i just revived a like 15 year old thread? my bad guys. **** me.


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