Lesson From The Street: Skin Doesn’t Lie

I hope you’re sitting down for this. I trust that a good number of my readers do indeed sit while surfing the internet so I’m just going to tell you this strait up. Sometimes … patients lie. They do.  Occasionally they intentionally tell us bold, outright lies. And it gets worse. With even greater frequency they are just plain inaccurate. They may not be intentionally deceiving us, they may be confused, misinformed, exaggerating, in denial, overwhelmed or embarrassed. Regardless of the reason, we are frequently faced with subjective information that isn’t all together accurate.

What’s an EMT to do?

I don’t want to suggest that you should skip or disregard your subjective assessment. The things that your patient tells you are vital and important clinical findings. Even inaccurate information can give you vital clues regarding the patient’s mental status and physical condition. But I’d also suggest that you put a premium on physical findings that give you instant and accurate information about the patient’s physical condition. The longer I work in emergency service the more I find myself falling back on basic patient assessment truths like this one:

 

Pay attention to your patient’s skin.

Skin never lies. It tells you a wealth of information about the patients current state of oxygenation and circulatory function. It tells you about their medical history, their diet, their hydration status and their life. I want to challenge you to really look at your patient’s skin. On your initial exam look at their face and neck, then get closer and feel it. Feel the skins temperature and moisture on your gloves. Gently pinch their forearms and assess the turgor of the skin. Ask yourself what it means.

Assessing the skin means examining its:

Color

The patients skin has a wide range of normal and abnormal colors. All of them help tell a story about the body’s current state. Skin can be pale, flushed, mottled, cyanotic, jaundiced and a multitude of other tints. Learn what your patients skin is telling you about their oxygenation, renal and hepatic function, circulatory status and hydration.

Temperature

A patients skin temperature should be in balance with their surrounding temperature and activity level. Abnormally hot, cool or cold skin can speak volumes about the patients level of distress especially when their body is fighting infection or responding to hypoperfusion (shock).

Moisture

A classic scene from the movie Stepbrothers involves Will Ferrell trying to act casual after a jam session on his stepbrothers forbidden drum set. His stepbrother confronts him with, “Why are you sweating?” In one of the funnier lines of the movie Farrell gestures to the TV and replies, “I was watching Cops.”

Even the dimwitted stepbrother is smart enough to pick up on the medical truth, “skin doesn’t lie.” People sweat because of exertion, increased body temperature, stress and hypoperfusion. If the patient is sweating you need to ask yourself why. People become diaphoretic for a reason. If the reason isn’t apparent to you, you’re missing something.

 

Beyond the color, temperature and moisture assessments there is still more of the story to found in the patient’s skin turgor, nail beds, oral mucosa and conjunctiva. with practice, the patient’s skin can become your greatest physical assessment ally.

 

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  1. […] upon a time I explained that skin doesn’t lie and that’s probably one of the most compelling reasons why we need to pay attention to pale, […]