Paramedic Patient Contact

[ZootownMedic]

Hey everyone,

I am at the end of my first module of Paramedic school and things are going well. There are two areas that I am not so much 'struggling' in but need to work on. I am having difficulty with my initial patient contact and 'assessment' but let me clarify. I am not shy and I understand what needs to be done, however my lack of street experience is making it difficult for me to know whos 'sick' and 'not sick'. Furthermore, I am having trouble with the differentials and ruling things out. I know I will get better with the more patient contacts I have but do any of you have any advice from experience on ways I can improve in this area? Also, how do most of you experienced medics kinda roll through your initial patient contact so on. Thanks in advance.

 

[Shishkabob]

No advice to give, as you answered it yourself. The more you do, not only the better you'll get, but you'll also develop your own style on how you run your assessments. Watch how your preceptors run some calls if you want, but in the end, do what you feel is best. Your clinicals, internship and first year are where you learn the most about how you run calls. Give it time, and you'll be great. You'll miss things, so don't let it get to you. Even doctors, with decades of experience, miss things and screw up. Don't be so set on getting the "right" diagnosis... just the most proper diagnosis at the time.




The assessment is the single hardest thing we do, but there is no "correct" way to do it. Learn what works for you, and do it.

 

[ZootownMedic]

Thanks for the input. So for example the other day we had a 45 YOF that was complaining of left sided numbness. Her skin was P/C/D and she had a BP of 100/56. My mentor put her on a 12 lead and she had NSR. She was AAOx4 but didn't look well. During transport he asked me what I was thinking with her. I told him worst case scenario I was thinking AMI...or maybe TIA or CVA....but then I was kinda lost and it seemed like he was thinking of alot more differentials. Is that normal with the lack of experience? I felt kinda like a jackass....

 

[Shishkabob]

If you thought he had a different differential, why didn't you ask him what his thoughts were?


When I have students, even if it's an EMT student who didn't run the call, I ask them what they think it is. I ask them to explain their thoughts behind their differential. If their differential differs from mine, I put in my 2 cents to see if we can't discuss it. There will be times you're stumped, and as I said, it even happens to doctors, who have the luxury of many tests and more education, even though they're dealing with the same patients we are.




Sometimes you just have to take your best guess and go with it. Example: An asthmatic with COPD and CHF complaining of shortness of breath and chest pain. Been there, done that, still hate it.

 

[ZootownMedic]

Well I did, and he mentioned a couple things. he mentioned Hypoglycemia which I hadn't really thought about. She didn't have a history of diabetes, but he countered saying it could possibly be the day her pancreas decided not to work. In hindsight, I guess it wouldn't have been hard for me or one of the 100 firefighters there to get a d-stick and check he BGL. I guess yesterday just made me realize how much I don't know. Can I ask you a question Linuss? How do you usually start your patient contact, and questions? do you introduce yourself and go right for a radial? then OPQRST and the like? PtHx? Im talking about the generic medical call. Again, thanks!

 

[Shishkabob]

You're still in school, it's totally fine to not think of everything you should. Hell, there are members on this board who are very smart and have been in the field for a while and still can get stumped on calls. The human body, and it's illnesses, are very complex things as you know realize. That's why Paramedicine, and medicine in general, is as much an art as it is a science.


Unless what we were called for is obvious (someone splurting blood, or a leg is at an angle that makes you go "That must hurt") the first thing I ask is "So what seems to be the problem today?". Even if dispatch tells us what the call is for, I ask it so I can hear it directly from the patient. We then go from there.


I don't like sticking to "OPQRST" and "SAMPLE", and often try to break my students of the habit of sticking to those as front line questions. Yes, while what I ask will essentially be those questions, they are in fact a lot more in depth and varied, and I'll deplete one line of questioning before I move on to the next.

I can't tell you how...slap-happy?... I get when a student goes "When did the onset occur" then go right to "What provokes it?" before even going down a path of questioning from the patients answer, as they pretty much ignore what the patient said and are too focused on asking their next question. They treat OPQRST and SAMPLE as the end of the line, never expanding on an answer a patient gives.


That's why you're taught to ask open ended questions, and not yes / no questions;

"What seems to be the problem today? Oh, your stomach hurts? When did that start? You say right after you ate lunch, were you doing anything active afterward or just sitting there? Ah, so you started going for a jog, so has this type of pain happened before after a jog?" Etc etc.




I honestly can't say what my 'usual' style is, as it's different for each patient and each call, and I just go with the flow.

 

[JPINFV]

Well I did, and he mentioned a couple things. he mentioned Hypoglycemia which I hadn't really thought about. She didn't have a history of diabetes, but he countered saying it could possibly be the day her pancreas decided not to work.

Unless her pancreas all of a sudden decided to start pumping out insulin (insulinomas are unlikely, but possible), it's highly unlikely. Hypoglycemia in patients with DM is largely due to the treatments, not the disease itself. Besides, you do have a point of care lab test for that. If hypoglycemia is on the radar, then there's absolutely no reason not to test.

How do you usually start your patient contact, and questions? do you introduce yourself and go right for a radial? then OPQRST and the like? PtHx? Im talking about the generic medical call. Again, thanks!

I'm not Linus, but...
"Hi, my name is JPINFV, and I'm going to be your second year medical student today. What's your name? ... Is it ok if I call you "_____?" What can I help you with today?"


...and...
http://emtmedicalstudent.wordpress.com/2010/11/15/interpersonal-communication/

 

[sir.shocksalot]

Differential diagnosis is just one of those things that comes with more knowledge and experience. Going over differentials with other providers (Doctors, other Medics, Basics etc.) will help you see other's thought processes. Here is the way I look at it in my head:

Pt is c/o chest pain. So what are the most common life threatening causes of chest pain: MI, PE, Thoracic Aortic Dissection/Aneurism(ruptured), Tension Pneumo, Esophageal rupture/tear(with significant hemorrhage).
I then go about ruling these in or out depending on physical findings, diagnostic tests, and patient history. For example,
MI: History, physical and 12-lead will rule this out or in.
PE: History, physical, and 12-lead will rule this out or in.
Thoracic Aortic Dissection: History, physical, 12-lead, and possibly Ultrasound will rule this out or in.
Tension pneumo: History and physical will rule this out or in.
Esophageal stuff: History and physical...
You get the picture. As you learn more about the patient's complaint other things will filter out and other things will filter in. So pain has been persistent for a week, associated with a cough. MI, Esophageal rupture, and tension pneumo become less likely but now you start to include things like, pneumonia, costochondritis, pleurisy, and pericarditis. The priority is to rule out the big things, or rule them in and treat accordingly. You don't need to have the diagnosis every time, you just can't miss the big ones that kill people.

This is by no means an inclusive guide to differentials, I am relatively new myself and learn something new all the time. But this is the way I do it, and this is the way I was taught, if you like it, use it, if not hopefully it helps get a system sorted out for you.

 

[mike1390]

quick ? just for my knowledge have you ever worked as an EMT? if so how long?

 

[usafmedic45]

I told him worst case scenario I was thinking AMI...or maybe TIA or CVA....but then I was kinda lost and it seemed like he was thinking of alot more differentials. Is that normal with the lack of experience? I felt kinda like a jackass....

Yeah, it's normal. You ever want to see someone who is utterly clueless, watch med students when they first hit the wards.

 

[ZootownMedic]

quick ? just for my knowledge have you ever worked as an EMT? if so how long?

I graduated from EMT school in summer of last year. Worked at a midsized fire department and ate up as much EMS as I could. Wish I coulda worked as a EMT longer but unfortunately my need to provide for my family and eagerness to move on to a higher level of care trumped this.....I am actually one of the top in my class at this point academically....I am just behind the curve compared to SOME of my peers in patient contact experience. They have been very helpful however and we constantly teach each other things(usually them more than me) everyday...

 

[ZootownMedic]

Thanks to everyone for the advice and comments. I think this last 3rd ride kinda hit me hard because I hadn't had patient contacts in so long. Combined with this was my unfamiliarity with the ambulance and care enroute. I am already getting it down and feeling better about things although I feel bad for those first two IV's I did in a moving ambulance....got the sticks...but everything went downhill after that trying to screw the saline lock in and get the IV secure haha....hate to laugh but its 99% directed at myself. Anyways...I guess theres no substitute for experience and that comes with time...

 

[Flightorbust]

smoke, Are you at ppcc? Also talk to the ER at memo and Penrose, see if you can volunteer. It will give you a chance to see how people present as well as you can find out what the issue truly was.

 

[CAOX3]

Unfortunately your just going to have to see patients there is no shortcut. Sick and not sick should come pretty quick, the origin of that sickness is going to come with education and experience.

 

[ZootownMedic]

smoke, Are you at ppcc? Also talk to the ER at memo and Penrose, see if you can volunteer. It will give you a chance to see how people present as well as you can find out what the issue truly was.

Yep! I used to work down at Stratmoor Hills FD and now I am trying to get hired on at Fountain FD to get that additional experience. I have my FF1 and Hazmat-Ops certs as well but don't really care for Firefighting all that much. I didn't know you could volly at the hospitals...I am gonna try to pick up as many extra third rides as I can too. Thanks for the advice

 

[Flightorbust]

I know Ive seen volunteers in the ER at main. If nothing else just go talk to em. They may make you into a free tech.

 

[johnrsemt]

OP: you asked for advice on initial patient contacts:

This is something that I do with all my patients; trauma, medical unknown, mental etc.

As I walk into patients area I start talking to them in a normal tone of voice. As I approach the patient I do a quick observation of the surrounding area, (looking for dangerous, scene safety type stuff) also what type of living conditions etc.
As I am talking (introducing myself to them, and asking their name and what is happening); to the patient I am seeing how alert the patient is by their responses.
Also I am looking at patient's condition: pale, flushed, white, normal, diaphoretic, etc.
When I get to touching range of patient, I will squat down (if patient is sitting); and reach out and lightly grasp wrist; checking a quick 5 second pulse: All I am looking for is strength, or weakness, fast slow absent, etc.

30 second approach with lots of information and works with all patients.

 

[Melclin]

I reckon half the problem with the teaching process when it comes to the "clinicaql approach" or your standardised approach to the pt, is that people get bogged down in what they think they're supposed to be doing and the specific order of everything, that they forget to just talk to the people.

First impression dictates a lot. I have a book for medical interns called "On call" which calls it the quick look test, which I like.

My approach, for what its worth, is similar to John's. I suppose this is an adequate reflection. It feels odd to put it down on "paper" like this.

Quick look test: Are they "Big sick", "little sick", or "not sick". Just a gut feeling, it can and should be revised later. Based largely on responsiveness as I enter the room and skin colour. To me:
-Big sick, means the next step is a formal primary survey.
-Little sick means I take their vitals during my initial chat to them and I'm a bit more direct.
-Not sick* (most pts) generally means I'm sitting down if possible and doing five minutes or more of history taking before I even bother with vitals.


Initial approach (+/- vitals) :For little sick and not sick: Introduce myself and my partner. Get their name. Shake their hand (Is their hand warm? Mental status adequate to follow the social norm? Plus old blokes like it). Ask them what brings me here today. I don't follow a particular set of questions initially, I just prompt them into painting a clearer picture of all the events and timing surrounding the chief complaint and associated symptoms. With each problem I ask, 1) Is it new or normal for them? 2)Have they ever felt anything like it before? Once they've listed all their complaints, I then run through the pertinent negatives. Chest pain? SOB? Dizzy? Palpitations? Nausea? etc based on what they've said. As I said, if they're little sick or I have MICA coming, I'll do some vitals simultaneously.

Targeted hx and physical (+/- vitals):Then based on what they've said, a differential will appear in my head, I start with targeted hx of physical exam looking at knocking things off/up that list. I have a standard set of questions/exams that I do for common serious problems, that will generally come first if any of them are in my ddx.
For a stroke symptom for example the standard set is: GCS, BSL. Pupils, visual acuity. Swallowing? Any trouble hearing? Head/neck pain? Any stroke/TIA hx? Strength/sensation in each limb? Have them walk across the room and back. Trouble walking/balance/dizziness/vertigo?

Look at their meds and have a quick word about their medical hx in general. Specifically prompt common problems. MI, stroke, COPD, asthma, diabetes etc.

Decisions: Then comes a decision on a working diagnosis and what care pathway is appropriate for them (Self care, GP, some kind of community based health service, LOCUM, case worker, hospital, direct admission, Intensive care paramedic back up, Chopper).

Thoroughness: A more thorough hx and physical will then follow in the truck if we transport, if not, we'll do it on scene. Involves general hx taking that pretty much everyone gets. Opening bowels/micturition, oral intake, exercise, recent coughs/colds/flu like symptoms etc, sleeping patterns, recent falls, hospital admission in the past 5 years, surgeries (a lot of this is more for older people) if they weren't already part of the targeted hx.

I dunno how well this really reflects how I go about it, but its seems like a reasonable sketch.

I standardised certain questions sets so I could get things done, quicker with greater consistency while being paralytically tired. Its worked well for me as a newbie so far and I'd recommend it in some way shape or form.

*Doesn't actually mean their is nothing wrong with them. Its just a play on the idea that most shifts, I'll go to multiple jobs where I walk into a room with a few people in it and have to ask to who the patient is because every one looks perfectly healthy.

 

[sirengirl]

There was a running joke at the station I used to work at (before I started medic) that you can always tell who the new EMTs are because they will talk to their patients like this:

EMT: "Okay sir/ma'am, what are your signs and symptoms."
Pt: "Well, my chest hurts."
EMT: "What are your allergies?"
Pt: "Well, peanuts make me feel funny."
EMT: "What medications are you on?"
Pt: "I carry an Epi pen."
EMT: "What is your past pertinent history."
Pt: ".....what?"

In all honesty you just have to remember that you're working with a person who has emotions and worries and fears, and who may be a great person or an a$$hole, who has a family and a life and is currently having an emergency. I've always just had normal conversations with my patients, and no two are alike but all of them ask all the questions that need to be asked in a natural manner. You'll develop your own routine, the same way I did, and they won't even be remotely similar, but they'll get the job done. Usually for me, I just walk in the door, crouch in front of my patient, and say, "Hi, my name's Kara, what's goin' on today?"