IFT Assesments

emtbls

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So I've been fooling myself into believing real-life field medical or trauma assessments are the same as proctored exams in a classroom. (i.e. verbalize BSI, you can take your time - anything under 12 mins is great!):rofl::rofl::rofl:

Please give me some suggestions on how to get the best information and go from 'arrival time' to 'packaged for transport' in 5 mins or less!

I'm struggling with good questions for A/O that won't insult. Tips for getting HR and respirations all while smooth talking a SAMPLE history out of a little old grandma.

Anything helps, thanks in advance.
EMTom
 
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why the rush. take your time and do a good assessment.
What do you ask for A/O questions?
 
What's your name?
Where are you?
What day is it?
What happened?

The A&O questions actually serve a purpose on evaluating memory at different spans of time. It's really not that awkward.

Like Tim said, there's really no rush. If they're that bad off that you need to leave ASAP, they likely can't answer your questions anyway. If they aren't, then slow down and relax.
 
why the rush. take your time and do a good assessment.
What do you ask for A/O questions?

What's your name? what's your last name? Person
Do you know where you are? Place
Do you know what day it is? Do you know what time it is? Time
Do you know who the president is? Event

I think some of my less altered pt may find it rude to ask if they know these basic things, am I wrong?
 
Just tell them you're going to ask them some simple/silly questions to better evaluate them. I've never had anyone tell me I was rude for it.

And event is typically what happened/whats happening- asking what today's event was, ie present illness or injury.
 
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What's your name? what's your last name? Person
Do you know where you are? Place
Do you know what day it is? Do you know what time it is? Time
Do you know who the president is? Event

I think some of my less altered pt may find it rude to ask if they know these basic things, am I wrong?

not bad
I try to avoid political talk as it can get some ppl going.

I usually tell them I have some silly questions I have to ask everyone

what is your name and birthday?
what day or month is it?
where are you right now?
what happened?

The event question should be relevant to what happened, but besides that your questions are great.
 
why the rush. take your time and do a good assessment.

I'm all for a thorough assessment, but if a dialysis pt is fealing weak, I want to be able to get a good history when transferring care.
 
I think some of my less altered pt may find it rude to ask if they know these basic things, am I wrong?

Identifying your patient is the first step. In the hospital a patient will be asked for their name and date of birth at least 50 times a day along with an ID band check by everyone from dietary to the RN who just saw the patient 20 minutes prior. By the end of their hospital stay some patients will have their MR number memorized also. If the patient is nonverbal, another staff member must be present to confirm identity. Occasionally we will have an ambulance crew try to take the wrong patient because they were going just by a room number their dispatch gave them which might have changed since the arrangements were made.

But, establishing a baseline for mentation will also keep you from being embarrassed later when these questions are asked on arrival and the accepting staff wants to know if there was a change.
 
not bad
I try to avoid political talk as it can get some ppl going.

I usually tell them I have some silly questions I have to ask everyone

what is your name and birthday?
what day or month is it?
where are you right now?
what happened?

The event question should be relevant to what happened, but besides that your questions are great.
I do pretty much the same things. Also, during conversation, I look for repetitiveness or an attempt to dodge the questions. My neighbor's Dad is a prime example. He's not doing all that well, actually. He dodges those questions and has a few things he says, but if you were to talk to him for about 20 minutes (less sometimes) it's obvious he's not doing well.

Something I also do is I use "what happened" for events, I also explore a bit for the SAMPLE History. You can get signs, symptoms, and events just by asking a couple more questions about "what happened." Then I'll usually ask:

  • Are you allergic to any medications or foods?
  • Do you take any medications or supplements? Where are they?
  • What do you take them for/Do you have any problems that the doctor needs to know about?
  • When did you last eat, and what was it? (Gets them thinking about their last meal, and opens a potential line of communication: food!)
  • Did you drink any beverages with that? How much water do you drink daily?
  • When did you last pee/poop? Any chance you might be pregnant?
I ask these things pretty quickly during other patient-care activities, so I don't take up much time. Those are the quick & dirty things I need to know right away. After that, I can take a LOT more time in the ambulance to get into more depth about things. Something I also do is chat with my patients during transport because it gets me more used to their usual manner of speech and serves as a continual monitoring of mental status.

You'll learn what works for you as you do them. I really enjoyed my time doing IFT's because it gave me time to practice doing assessments. I also enjoyed them because the patients were sicker, more complex, so I had to think about their issues. There's also often less of a need to be super-speedy during those, so you have time to be more thorough while on-scene. Speed while on-scene will develop with time too. When I last did 911, my scene times were typically less than 8 minutes. Trust me, I didn't get that fast overnight. My fastest scene time was about 68 seconds... but that was a special case and there was positive suitcase sign on that one. ;)
 
For AO, go for this: Hi, I'm exodus, what's your name? Nice to meet you, do you know where we're taking you today? I just want to make sure everyone on the same page! (Later on) Oh, I"m sorry, I've seemed to have forgotten the date, do you happen to know it?
 
For AO, go for this: Hi, I'm exodus, what's your name? Nice to meet you, do you know where we're taking you today? I just want to make sure everyone on the same page! (Later on) Oh, I"m sorry, I've seemed to have forgotten the date, do you happen to know it?

I wouldn't pretend to not know something simple like the date. At best they think you're forgetful and/or dumb, at worst you've just insulted their intelligence. I'd stick with "can you tell me what today is?" day of the week or date is fine, and if they ask just tell them it's a simple, quick, and typical assessment of their mental status.
 
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I always preface the A&O type questions with something along the lines of, "I need to ask you a few silly questions." I also tend to ask for the year or day of the week. Half the time I am checking my watch for the date, so I don't think it is unusual to not know it.
 
To the OP, you'll be making a big mistake if you rush IFT calls. It's easy to make a mistake: take the patient to wrong location, not have the proper information, paperwork, and/or signatures to bill the patient's insurance, etc. Often these patients are not acute either so there is little reason to be in such a rush. I aim to be on scene for about 20 minutes.

I usually get the patient's demographics and billing information from their face sheet.

Get their medications and allergies from their medication administration record (MAR). If the MAR is large, I'll attach a copy of that to my paperwork and document "Refer to attached paperwork."

Review their chart to look for their past medical history (PMH). If it's large, I'll attach to my paperwork and document "Refer to attached paperwork."

Always attach a copy of the patient's facesheet to the prehospital/patient care report (PCR). If it's a wait and return, it'll be two separate PCRs and require two of everything such as facesheet.

Check the facesheet to see if the patient has Medicare or MediCal insurance. If so, have the sending RN fill out a Physician Certification Statement (PCS). If it's MediCal, it needs to be signed by a physician.

Get a report from the sending RN. I'll verify where the patient is being transported to, ask why they are they being transported there, why can they not stay, why do they require an ambulance, and are they a full code. Those are very important to document for billing.

10 Presumptive Medicare Criteria

Unconscious or shock
Emergency (ie car accident)
Restraints
Immobilized or c-spine
Hemorrhage
Bed confined*
Oxygen
Can only be moved by stretcher
Stroke
Respiratory or cardiac signs and symptoms

Bed Confined

Unable to get out of bed without assistants.
Unable to ambulate.
Unable to sit in a wheelchair.

You should ask the sending RN other questions that pertain to the patient eg if they are on a 5150 hold (California's 72-hours psychiatric hold), ask the RN: Why was the patient placed on a 5150 hold? Do they have suicidal ideation (I often hear RNs say "SI" literally)? Do they want to harm others? Are they gravely disabled? Did they have a plan (suicide)? Have they had psychiatric care before? How many times before? Were they calm and cooperate during their stay? Do they require restraints? Document and report these to the receiving staff.

If they have a Physician Orders of Life-Sustaining Treatment (POLST) or a Do Not Resuscitation (DNR) form, I'll check if it's valid, and ask for a copy of it to attach to my paperwork. In Santa Clara County, I can honor a DNR without having the original, but I need evidence (eg copy of DNR). In Alameda County and Contra Costa County, the original DNR needs to stay with the patient to be honored.

III. Procedures

A. If upon Prehospital personnel arrival the patient is determined to be pulseless and apneic:

1. Establish DNR / Advanced Directives / Code Status

2. A Prehospital care provider may withhold or discontinue resuscitative efforts in the following circumstances:
a. The prehospital care provider identifies a signed DNR Form (original or copy), a No Code order on the chart, a DNR Medallion, a POLST, or a DPAHC that clearly states Do Not Resuscitate
Santa Clara County EMS - Do Not Resuscitate (DNR) / Advanced Directives - Policy 604

If the patient is being transported for psychiatric care, check that I am being sent with the original 5150, it's correctly filled out and signed, and ask for a copy to be attached to my paperwork.

I am unfamiliar with other companies doing this, but my company wants me to make every effort to get a copy of the patient's ID (eg driver license) and proof of insurance.

I'll get the sending RN's last set of vitals from the EMTALA form the patient is being sent with, or from the RN's chart prior to transport.

Introduce yourself to the patient, and ask 'em what do they like to go by (that's how you assess person). Try small talks while preparing to transfer the patient to the gurney eg "How long have you been in the hospital?" (that's how you assess place and time). Those are example questions. It's really easy to obtain person, place, time, and event without being awkward. This is the time to get the history of present illness (HPI). Common basic questions for HPI are OPQRST for (chest) pain and PASTE for shortness of breath.

O - Onset - What were you doing when the pain started? Was it slow and progressive, or was it sudden pain?
P - Provoking/Palliating - What makes it better or worse?
Q - Quality - Describe What it feels like to me please.
R - Radiating/Region - Where is the pain? Has it spread out? Where does it hurt the most?
S - Severity - On a scale from 1 to 10, 1 being little pain to 10 being the worst pain you can imagine, what would you rate this as?
T - Time - When did the pain start? How long have you had this pain?

P - Provoking/Palliating - Refer to P in OPQRST.
A - Associated sign and symptoms (chest pain) - Do you have any chest pain? Have you had any other problems lately?
S - Sputum - Have you been coughing up anything?
T - Time/Talk/Tiredness - Note the number of words they are saying in between breaths.
E - Exercise tolerance - Are you normally about to do this? How about now?

Use the mnemonics as needed. For example, if the patient was hit by a car, it's probably inappropriate to ask 'em the onset, probably quality, radiating, and time of pain. Add as needed like those 5150 questions I shared. Note: Patients and family members may be uncomfortable with you asking some questions, it might be better to wait until you're in the back of the ambulance.

Do a quick visual exam. If they are wearing a jacket or sweater, have the remove it. It'll be easier for you to do a quick visual exam, and it'll be easier to do vital signs during transport. You can give the patient a blanket and turn on the heat during transport if they are cold; keep the jacket/sweater off. For 5150s, the sending facility will sometimes forget to remove the patient's IV, and the receiving facility will not accept the patient unless the IV is removed. Common things you'll see in IFT are: IVs, peritoneal dialysis, perm cath, pacemakers, AV fistulas (palpate for a thrill), scars, colostomy bags, g-tubes, and PICC lines.

IV gauge size - Color of IV hub

14G - Orange
16G - Grey
18G - Green
20G - Pink
22G - Blue
24G - Yellow

My company wants me to always assess and document their respiratory, neurological, and circulatory status.

...

Well, I am getting too lazy to finish this. I have a ton of work to do. Maybe later? :[
 
To the OP, you'll be making a big mistake if you rush IFT calls. It's easy to make a mistake: take the patient to wrong location, not have the proper information, paperwork, and/or signatures to bill the patient's insurance, etc. Often these patients are not acute either so there is little reason to be in such a rush. I aim to be on scene for about 20 minutes.

I usually get the patient's demographics and billing information from their face sheet.

Get their medications and allergies from their medication administration record (MAR). If the MAR is large, I'll attach a copy of that to my paperwork and document "Refer to attached paperwork."

Review their chart to look for their past medical history (PMH). If it's large, I'll attach to my paperwork and document "Refer to attached paperwork."

Always attach a copy of the patient's facesheet to the prehospital/patient care report (PCR). If it's a wait and return, it'll be two separate PCRs and require two of everything such as facesheet.

Check the facesheet to see if the patient has Medicare or MediCal insurance. If so, have the sending RN fill out a Physician Certification Statement (PCS). If it's MediCal, it needs to be signed by a physician.

Get a report from the sending RN. I'll verify where the patient is being transported to, ask why they are they being transported there, why can they not stay, why do they require an ambulance, and are they a full code. Those are very important to document for billing.





You should ask the sending RN other questions that pertain to the patient eg if they are on a 5150 hold (California's 72-hours psychiatric hold), ask the RN: Why was the patient placed on a 5150 hold? Do they have suicidal ideation (I often hear RNs say "SI" literally)? Do they want to harm others? Are they gravely disabled? Did they have a plan (suicide)? Have they had psychiatric care before? How many times before? Were they calm and cooperate during their stay? Do they require restraints? Document and report these to the receiving staff.

If they have a Physician Orders of Life-Sustaining Treatment (POLST) or a Do Not Resuscitation (DNR) form, I'll check if it's valid, and ask for a copy of it to attach to my paperwork. In Santa Clara County, I can honor a DNR without having the original, but I need evidence (eg copy of DNR). In Alameda County and Contra Costa County, the original DNR needs to stay with the patient to be honored.


Santa Clara County EMS - Do Not Resuscitate (DNR) / Advanced Directives - Policy 604

If the patient is being transported for psychiatric care, check that I am being sent with the original 5150, it's correctly filled out and signed, and ask for a copy to be attached to my paperwork.

I am unfamiliar with other companies doing this, but my company wants me to make every effort to get a copy of the patient's ID (eg driver license) and proof of insurance.

I'll get the sending RN's last set of vitals from the EMTALA form the patient is being sent with, or from the RN's chart prior to transport.

Introduce yourself to the patient, and ask 'em what do they like to go by (that's how you assess person). Try small talks while preparing to transfer the patient to the gurney eg "How long have you been in the hospital?" (that's how you assess place and time). Those are example questions. It's really easy to obtain person, place, time, and event without being awkward. This is the time to get the history of present illness (HPI). Common basic questions for HPI are OPQRST for (chest) pain and PASTE for shortness of breath.





Use the mnemonics as needed. For example, if the patient was hit by a car, it's probably inappropriate to ask 'em the onset, probably quality, radiating, and time of pain. Add as needed like those 5150 questions I shared. Note: Patients and family members may be uncomfortable with you asking some questions, it might be better to wait until you're in the back of the ambulance.

Do a quick visual exam. If they are wearing a jacket or sweater, have the remove it. It'll be easier for you to do a quick visual exam, and it'll be easier to do vital signs during transport. You can give the patient a blanket and turn on the heat during transport if they are cold; keep the jacket/sweater off. For 5150s, the sending facility will sometimes forget to remove the patient's IV, and the receiving facility will not accept the patient unless the IV is removed. Common things you'll see in IFT are: IVs, peritoneal dialysis, perm cath, pacemakers, AV fistulas (palpate for a thrill), scars, colostomy bags, g-tubes, and PICC lines.



My company wants me to always assess and document their respiratory, neurological, and circulatory status.

...

Well, I am getting too lazy to finish this. I have a ton of work to do. Maybe later? :[

This needs to become a sticky! :)
 
Well, I am getting too lazy to finish this. I have a ton of work to do. Maybe later? :[

Self-props.......

In all seriousness, very nice post Aprz ;)
 
Aprz pretty much hit the nail on the head. OP just remember each company is going to be slightly different in what exactly they want in terms of paperwork PCRs. Your company will be slightly different than Aprz's, which will be slightly different than mine, and so on. Refer to your employee operational guidelines. Ideally you should be able to ask a supervisor or an FTO at your company, but if real world factors make that impracticable, ask your partner or a friend who's been there longer
 
To the OP, you'll be making a big mistake if you rush IFT calls. It's easy to make a mistake: take the patient to wrong location, not have the proper information, paperwork, and/or signatures to bill the patient's insurance, etc. Often these patients are not acute either so there is little reason to be in such a rush. I aim to be on scene for about 20 minutes.


Well, I am getting too lazy to finish this. I have a ton of work to do. Maybe later? :[

Aprz, thanks for such an in depth guide. Please finish later if you have the time, I have a new goal to create specific questions for various ailments - i.e. chest pain vs. psych vs. mechanical falls. These diagnostic exams must be the secret weapons of allstar EMT's
 
Aprz, thanks for such an in depth guide. Please finish later if you have the time, I have a new goal to create specific questions for various ailments - i.e. chest pain vs. psych vs. mechanical falls. These diagnostic exams must be the secret weapons of allstar EMT's
IMHO, the "all star" EMT's advantage is knowledge of normal A&P. If you know what normal is, it's easier to discover what's abnormal and ask questions about that. If they have good knowledge of pathohys, they'll be even better at it. Those questions above just get them started... and from there it's off to the races, so to speak.
 
I'm going to second that DNR check. Every single DNR from every major hospital I've been given was not legally valid (due to no patient/surrogate signature). I've spent up to an hour and a half getting a legally valid one before we could move out. They'd hand me the DNR and I'd hand it back and point out that it wasn't signed by the patient or a surrogate and it wasn't legally valid. Every time the RNs on staff would try to get me to accept it anyway and I'd tell them we would need to transport the patient as a full code and ask them to contact the family for permission. I don't leave until I have a valid DNR... I don't need that kind of drama coming back on me if the patient heads south enroute.

I've had to educate both hospitals and hospice centers regarding DNRs, it's quite surprising actually.
 
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