Lots of things can affect our decision making capacity. Our patient’s ability to understand and make decisions is an important aspect of our patient assessment. It also has a great deal of bearing on how smoothly our interactions with them will progress and just how many options we want to offer them for consideration.

Our patients’ can be allowed varying degrees of autonomy, depending on our assessment of their decision making capacity, but are they able to refuse our care?

The ability to assess true decision making capacity becomes critically important when the decision to refuse care is in question. Lots of folks try to refuse our care, but not all can.

Often, when a patient requests to not be transported in an ambulance to the hospital, our minds first race to address the age issue. Age is a great determining factor for refusals because it’s so objective. The patient is either of legal age to refuse care or they are not…simple enough. Is it any wonder why it’s our first thought?

But it can’t be our only thought. Beyond age, there are numerous considerations. Head injury, neurological etiologies, pre-existing mental disability, drug and alcohol consumption can all play a role in our patients’ ability to make decisions for themselves, but none of them are a slam dunk.

When the troublesome question of mental capacity and the ability to refuse care rears its ugly head, here are four questions to consider before forcing the issue.

Consider all you know about your patients mental status and ask yourself:

1) Are they able to communicate a choice?

If the patient is unable to articulate that there is a choice being presented to them, the cannot make a rational choice. Ask the patient, “So what are the options available to you right now?” Or, if they insist on a single course of action (ie. “I want to go back to the store!”) gently ask, “As opposed to what?”

See if the patient can recognize and express that they are aware that there are several choices or options for the future and they are clearly choosing one over the other. If the conversation doesn’t lead there naturally, you can prompt the discussion by asking, “What other choices do you have right now?”

Make sure the patient knows that receiving medical care (from you and/or the hospital) are two of the choices placed before them.

2) Are they able to understand information relevant to their situation?

The patient’s ability to understand the relevant information is critical to their ability to refuse care. Telling an elderly female that you are concerned that she might be having a CVA is not acceptable. She needs to have the concept of a CVA broken down for her.

She needs to understand the risks involved in allowing a CVA to progress. She needs to understand that her current state may worsen without intervention and her long-term prognosis may be dramatically different if she seeks care now instead of later.

This can be a difficult prospect for EMT’s and paramedics who are unaccustomed to teaching complex medical conditions to non-medical personnel. Some of our patients need to have it broken down Sesame Street style. If the patient doesn’t understand their current medical condition, they can’t make an autonomous choice.

That doesn’t absolve you of the responsibility to teach them what they need to know. You don’t need to break out the dry-erase board, but you do need to explain their condition and your concerns in real-world terms.

3) Are thy able to assign personal value to their situation?

Ask the patient simply and plainly, “Mr. Jones, I’m worried that you may be having a heart attack. If you are having a heart attack and I leave you here with your family do you understand what could happen?”

Don’t take a simple yes or no as an answer. This is too important for a yes or no. If the patient answers yes, ask them to elaborate. “OK, what could happen? I’d like to hear you say it?” Be respectful, but make it clear that, before you allow a patient to sign an against-medical-advice refusal, you’d like to hear them say what the worst thing is that could happen to them after you leave.

What you want to know is that the patient understands that their choice has very real consequences. Not just theoretical consequences, real consequences, to them, personally.

4) Do they have an acceptable alternate disposition?

This isn’t as complicated as it sounds. What will there situation be after you leave? Are you leaving them in a reasonably safe location? Are they with another competent individual who can assist them if their situation worsens? Leaving a potentially sick person at home with a loved is acceptable. Leaving a person walking down the freeway in a snowstorm is unacceptable.

This doesn’t mean that you are required to find an alternate safe disposition for the patient. It simply means that, if they are unable to provide one for themselves, they should be transported to a safer location.

Another important factor to consider is the patients access to reliable communication. The patient should have access to some means for contacting us if their situation worsens. Confirming that the patient can get help if they decide that they need it is part of providing an appropriate disposition.

5) Are they able to rationally reach a decision that is stable over time?

Some folks just aren’t mentally stable enough to state their intended course of action and then stick to it. These patients can be phenomenally frustrating to manage. In one moment, they want to go to their brothers house across town. Then they want to be seen at the hospital. Then they are certain that they want to go back home. A minute later they want to call a friend and see if they are available to come pick them up.

If a patient can’t specifically and coherently communicate the direction they want to go, they can’t refuse care. A patients will, their desire to move forward in a certain direction, must remain stable over time.

This doesn’t mean that the patient can’t change their mind. If the patient is presented with new information and chooses to move in a different direction, they are certainly capable of doing so. But if you get a sense that the patient is jumping from one desire to the next without coherence or rationale, you ca simply decide to transport them because of their practical instability.

Irrational, flighty patients can’t refuse care. Don’t feel like you have to spend an inordinate amount of time catering to their ever changing whims. Put a reasonable time frame on their decision making process and stick to it. When time is up, transport.

The underlying caveat to all of this is the necessity of documentation.  The law actually allows you tremendous leeway on patient disposition. The important point is that you document why you made your final choice. When in doubt, always act in the patients best interest.

Whether the patient comes with you to the hospital or stays at home might not be nearly as important as your detailed documentation explaining why you made the choice that you did.

When documenting your decision, make sure you remember to mention the patient’s ability (or lack of ability) to communicate a choice, understand their situation, assign personal value to their decision and remain stable in their choice. If you forget all of the piece to that patient refusal puzzle, pull out your smart phone and come back here. I’ll be waiting.

Now it’s your turn. : What else do you evaluate when you are deciding to accept a patient’s refusal or deny it?

]]> http://theemtspot.com/2012/04/10/do-they-have-decision-making-capacity/feed/ 4 http://theemtspot.com/2012/03/14/suicidal-evaluation-the-dead-pimp-assessment/ http://theemtspot.com/2012/03/14/suicidal-evaluation-the-dead-pimp-assessment/#comments Wed, 14 Mar 2012 17:48:10 +0000 Steve Whitehead http://theemtspot.com/?p=5059 It’s a difficult situation that just about every EMS provider has been faced with at some point. Someone, somewhere thinks a friend or loved-one wants to commit suicide and they call 911. You arrive on scene to find a healthy looking patient who is adamant that they have no desire to harm themselves or anyone else. They don’t want to go with you. And now, you’re faced with a challenging evaluation.

This is a situation that experienced mental health professionals can find difficult. You have very little mental health training and you’re being asked to make a complex prediction about the potential future behavior of a person whom you’ve never met. What’s an EMT to do?

Thomas Dunn is in a unique position to talk to EMS providers about evaluating patients with potential mental illness. Thom is an active paramedic in downtown Denver, Colorado who routinely works shifts on a busy urban ambulance. He’s also a clinical psychologist who evaluates and treats patients’ at Denver Health Medical Center. Thom’s dual specialty makes him a rare specialist in human psychology as it applies to EMS providers.

When he talks, EMS providers listen…and so should you.

To help with this challenging potential suicide evaluation, Thom has come up with a fantastic acronym (in his unique paramedic style) to help remember what questions you might want to ask to determine the patients true risk of committing suicide. All of these elements influence the patient’s likelihood of ultimately harming themselves. To help us make the right call, Thom gives us the D.E.A.D. P.I.M.P. evaluation.

Before we jump too far into the acronym, let’s start by recognizing that, before we ultimately reach a decision about a potentially suicidal patient, we need to talk to the base physician. This is ultimately a medical consult between multiple trained medical personnel. The DEAD PIMP assessment is going to help you have that conversation with the physician based on real information about the patient’s true risk factors.

So now, for the first time on the inter-webs, Thom Dunn’s DEAD PIMP assessment:

D is for Disorder

Does the patient have a psychiatric history? Patients who have previous diagnosis of depression or more significant psychiatric disorders are more likely to attempt to harm themselves. Schizophrenics and bipolar disorder patients’ are most prone to suicide attempts.

E is for Environmental Stressors

Ask the patient if they are experiencing increased stress in their life. Take note of what kinds of things are happening in the patient’s life that may be causing undue stress. Events like divorce, forced separation from loved ones, death of a family member or friend and loss of work or livelihood are serious life stressors. If the patient reports one or more significant events that are causing them stress, it’s worth paying attention.

A is for Access to Firearms

Patients’ with immediate access to firearms are far more likely to successfully kill themselves. Often, all that is necessary to prevent these events is to place the firearm in a state that requires thought before use. Ask how accessible the firearm is to the patient. Is the weapon loaded? Are the ammunition and the firearm in the same location or separate? Is there a trigger guard? If so, where is the key? Patient’s who are at risk for suicide should be encouraged to make their firearm less accessible while they are going through their challenges.

D is for Disinhibition

Disinhibition is a complex way of saying something is affecting the patients frontal cortex reasoning and their willingness to inhibit their own behavior. Alcohol and drug use are the two most common reasons for disinhibition that we see in the prehospital setting but dementia and head injury histories can also lead to general disinhibition. Is the patient in a disinhibited state? Have they consumed alcohol or drugs? Do they have a medical history that may impair their ability to make good decisions and use good judgment?

P is for Previous Attempts

Patient’s who have previously attempted suicide are in a much higher risk category for a future successful suicide attempt. This might be one fo the first questions you ask your patient if you are concerned about their risk of hurting themselves. “Sir have you ever attempted to harm yourself in the past?” If the answer is yes, listen closely to the circumstances behind that previous attempt. Are there similarities to what they are experiencing now?

I is for Ideation

Has the patient been thinking about hurting themselves? If so, what thoughts have they had? Have they had conversations with family or friends about harming themselves? Explore what kinds of thoughts the patient has been having regarding committing harm to themselves. The more frequent and detailed these thoughts have been, the more likely it is that the patient will eventually follow through on their thoughts.

M is for Male

It’s simply a matter of numbers. Males are more likely to attempt to harm themselves and they are way more likely to be ultimately successful at ending their lives.

P is for Plan

Planning is the next stage of suicidal ideation. If the patient reports thinking about suicide, ask them if they have a plan for how they might end their lives. You might be surprised by how many patients who report little or no suicidal ideation will willingly relate complex plans for how they might harm themselves. The more detailed and realistic the patient’s plan, the more likely it is that they will eventually carry out their plan.

While we’re talking about patient’s plans, how effective are different plans for committing suicide? Here’s a quick breakdown of different popular mechanisms for ending ones life and how frequently they result in success:

Firearms (82.5%)
Drowning (66%)
Hanging / Suffocation (61%)
Gas Poisoning (42%)
Jumping (34.5%)
Ingestion (1.5%)
Cutting (1.2%)

So there it is. The next time you’re evaluating a patient who may be wanting to harm themselves, think DEAD PIMP. Ask the questions and then call your base physician and consult on transport. With this acronym, you’ll know what you want to ask about, what you want to report to the physician and what you want to document after the fact.

What do you think? Is this an assessment that you can use?

Like anything else in medicine, widespread utilization also comes with widespread misunderstanding. The SAMPLE history is an educational gold standard for a reason. It’s a very effective tool for remembering the major components of a medical history.  It’s also often misused and highly inadequate when taught and utilized at face value.

Let’s review the SAMPLE history and talk a bit about how to use it correctly to get all the juicy bits of medical history that you need when treating our patient.

First, to make sure we’re all on the same page, let’s review the SAMPLE acronym. SAMPLE is a six part subjective assessment that covers a good deal of critical information that is typically gathered in a basic subjective patient assessment. To review the difference between subjective and objective assessments, check out the SOAP reporting format. SAMPLE stands for:

S – Symptoms (Signs are important but they are objective.)

A – Allergies

M – Medications

P – Past Medical History

L – Last Oral Intake (Sometimes also Last Menstrual Cycle.)

E – Events Leading Up To Present Illness / Injury

That’s pretty straight forward. But let’s dive a little deeper. The first thing I’d like to emphasize before we jump into the questions in a little more detail is this – a SAMPLE history is not over in six questions. They are never complete in six questions.

I emphasize this because that isn’t the way we typically teach it in EMT class. You run your scenario and you say to your skills instructor, “I’d like to know about her signs and symptoms, allergies, medications, history, oral intake and prior events. And then the instructor dutifully rattles off a list of information. Do this over and over again and you may get the idea that your SAMPLE history will be six questions long and take approximately 2 minutes to complete.

In truth, the SAMPLE history, when done correctly, is a time consuming and detailed interview that may begin in the first few moments of patient care and continue until your walking through the doors at the emergency room. Good SAMPLE histories can be disorderly and divergent. They go off on tangents. They explore deeper than the basic questions. They encourage the patient to talk and elaborate (when the patient is able).

If you remember only one thing about this post when you show up to work tomorrow, remember this, a good SAMPLE history will take more than six questions to finish. If you accept the first detail that your patient volunteer and then move on to the next subject, you’re going to miss a bunch of stuff.

Let’s look at each question with a bit more detail. I’d like to identify many of the common ways that we can diverge from the basic question to get a better picture of our patient’s predicament.

Symptoms (And occasionally signs)

While the patient may report physical signs as their subjective complaints (i.e. My fingernails turned blue. I can’t move my legs.) for the most part, reported complaints are subjective in nature. I like to start my SAMPLE with a broad and open ended question like, “So what’s going on today?” or “Can you tell me what’s been bothering you today?”

For our injury patients, questions like, “What happened?” or the slightly less broad but time saving, “What exactly happened to you?” might be good starting points. Be ready to ask follow up and exploratory questions like, “What else happened?” or “What did you feel then?”

The good opening symptom question will encourage the patient to tell us, in their own words, what they are feeling and what physically happened to them. We may need to keep the patient from veering off to far into the events leading up to the illness or injury. If you feel like you have a handle on their specific complaints, let them diverge. You can always come back. But don’t be afraid to pull them back on topic until you have a good understanding of what they are experiencing right now.

Try to avoid long lists of closed ended questions like, “Do you feel chest pain?”, “Do you feel shortness of breath?”, “Do you feel dizzy?” You can spend a long time working through symptom checklists and never come anywhere near the true patient complaint. An earnest, “Tell me what you are feeling?” can get you to the point so much faster than a long list of closed ended questions.

Also know that you will frequently end up diverging into your full QPQRST before you move off of the “S” in SAMPLE. That’s OK. Go where you need to go. Another hint on OPQRST…it isn’t six questions either.

Allergies

“Have you ever had an allergic reaction?” is a good place to start with the allergies portion of your SAMPLE. This will often prompt the patient to begin by telling you about their most significant allergic episode. This may be medical or environmental. We often start with a medications specific question. I don’t think this is the best way to go. I’d prefer to start with the most significant allergy.

This also avoids glossing over significant allergies to bites, stings, latex, food or other, non-medication related stimuli. I also follow up with, “What other things have you been allergic too?” Keep going until the patient runs out of answers.

Medications

I know there are some providers who will probably disagree with me on this point but, for our patients with extensive medication lists, I don’t spend a bunch of time trying to get them to name all of their medications. If they can rattle off the list, I’ll certainly write it down, but few people who take more than three medications can list them off.

This is especially true for our patients who have their medications nearby. If we’ve found a big pile of medications, I’ll probably ask something like, “Are these all of your medications?” or “Where else do you keep your medications?” and then be done with it. I’d rather read the medication list and jump right into medical history instead.

There are a few more vital questions to ask before you move off of the medication list. One is, “Are you taking all of your medications?” I’ll usually follow this up with a few questions about how often the patient takes a prescription medication. “Mrs. Goldberg, how often are you supposed to take your Lisinopril?” The goal is to get an idea of how well versed the patient is in their medication dosing and frequency. If the patient struggles with the follow up questions, we need to consider that non-compliance (not taking prescribed meds as prescribed) may be an issue.

Another way to root out possible medication non-compliance is to ask, “Have you stopped taking any of your medications? You will often find that, due to unwanted side effects, many patients simply quit taking medicine that they have been prescribed. Not the medicines that have been discontinued and explore why the patient quit taking the medicine.

It’s also worthwhile to ask if there are any non-prescription medications that the patient takes. This includes over the counter medications, herbal medicines and alternative medications. You also want to ask about drugs and alcohol consumption. This is a good place to include that question.

Past Medical History

Once you have a good idea what medicines, the next are to move into is an exploration of why those medications are consumed. If I already have a makeshift list of medical ailments I may start by reviewing what I already know about the patient’s medical history. “So, Mr. Jones, it sounds to me like you have high blood pressure, high cholesterol and gout. Is that correct? What other medical conditions do you have?”

Be prepared for your initial assessment to be incorrect. Medications are often prescribed for multiple reasons. If the patient reports, “I don’t have gout.” follow up with a question about the medication that lead you to that assumption. “Why do you take Uloric?” The patient may only know that they take it for painful, swollen joints. Or you may learn about a new use for the medication in question.

After the patient is done with their full medical history, I often throw out one last question that can uncover hidden medical conditions. “Are there any other medical conditions that your doctor is concerned about?” Physicians will coach their patients about medical conditions that they are at risk for long before they make an official diagnosis. This question can give you great insight onto where the patient’s medical history is headed.

Last Oral Intake

I’ll admit it. For the first half of my medical career I almost completely ignored the patients last oral intake. With the exception of diabetics, I just didn’t see how the question could be useful to me. I was wrong.

I figured out that I was wrong when I finally started asking the question. Suddenly, I found a wealth of information about the patient’s appetite, social and daily activity, life stressors, questionable food intake and changes in diet regimen. The patient’s ability to eat, desire to eat and volume of food intake can give you great insight into what their life has been like in the 24 hours prior to the 911 call.

I also like to know what it was that the patient last ate and, if you can find a diplomatic way to ask, how much. When the patient tells me what they ate, I can often get a feel for how much they ate by asking, “Was it good?” What I really want to know is, how has their appetite been? I’d also like to know if they are newly dieting. I probe this by asking if they’ve had any recent changes in their dietary patterns.

If the patient’s symptoms are GI related I may tangent off into the quality of the food. Was any of their food intake in the last 24 hours sketchy? Was it prepared outside of the home? Did anyone else eat the same thing and, if so, are any of them feeling sick?

Events Leading Up To Present Illness or Injury

You may find that you end up covering some of the events leading up to patients 911 call when you ask about the patients symptoms. What the patient has been feeling tends to get twisted up with what the patient has been doing. If you diverge into OPQRST you will inevitably run up against the patients activities prior to their symptoms when you ask about provoking factors and symptom onset.

This is your opportunity to probe the patient’s recent activities a little further. Have they been active of static? Was there an emotional component to what was happening in the patients life at the time the symptoms began? Many of our patients’ are more prone to recognize symptoms when they are already upset about something else and some of our patient’s complaints can have a specific emotional component to them.

With trauma, we can get caught up in the details of the event itself and leave out one crucial detail, was there a medical symptom prior to the accident? When the patient describes a traumatic event, don’t forget to ask, “What made you (insert event here).” “Mr. Jones, What made you drive off the road?”, “Mrs. Sims, what made you fall down?”. When discussing the event, always consider a medical precipitating factor and adjust your questions accordingly.

When you’re versed in the different variations of the SAMPLE history and you stay focused on the global meaning behind the questions, you can feel free to let the questioning drift off on tangents. Take the questions to where they lead you. Return your patient back to the path when you’ve found all you can or strayed too far off topic. The SAMPLE technique is a well-worn trail, but it has lots side paths. Good subjective history takers are masters at exploring the side paths and always finding their way back to the main trail.

I’m a believer in AEIOUTIPS for several reasons.

Unlike mnemonics like my first cardiac arrest algorithm, (Shock, shock, shock. Everybody shock. Little shock, big shock, big shock, little shock.) AEIOUTIPS has remained relevant. That helpful cardiac arrest rhyme may have helped me through my first ACLS class, but it barely lasted through my first year as a paramedic. Once someone thought up high dose Epinephrine, things got complicated.

And, unlike more well known acronyms such as DCAP-BTLS-TIC, AEIOUTIPS has actual clinical application. That means I actually run through it in my head while I’m in the middle of patient care. I have never once exposed a trauma patients chest and actually though to myself, “OK, I don’t see any deformities…and I don’t see any contusions…and I don’t see any abrasions…” You see my point.

So what is this AEIOUTIPS acronym? It’s an acronym to help you remember the most common causes of altered mental status (AMS). This is useful when your patient is anything less than alert and oriented and you can’t figure out why.

Let’s face it, some differential diagnosis jump out at you. It isn’t tough to figure out what’s really  wrong with the dude that got hit by a car. The COPD patient who’s tripoding and breathing 30 shallow breaths a minute isn’t much of a mystery either. But the confused or unconscious patient can be a real puzzler.

The next time your patient has an altered mental status and you find yourself puzzled by what’s going on, manage the basics and run through the AEIOUTIPS acronym in your head.

A is for alcohol.

It’s first on the list for a reason. Alcohol plays a roll is a large percentage of the altered mental states that we encounter. Sometimes it’s obvious. Other times it isn’t. Does the patient have an odor on their breath? Does their environment suggest alcohol consumption?

E is for epilepsy (and other forms of seizure).

Could the patient have had a seizure? Inquire about the patients medical history and check their prescription medications. Do you note any oral trauma or urinary incontinence? Look closely for repetitive focal movement. Was the onset of altered mentation sudden?

I is for insulin.

Check the refrigerator (Insulin), the medicine cabinet and the patients body (Medicalert tags) for evidence of diabetes. Could the patient be hypoglycemic (or possibly hyperglycemic). Don’t forget a routine glucose check on all of your altered mental status patients. The ones we can’t figure out tend to always get their blood glucose checked. It’s when we are convinced that the cause of altered mentation is something else on the list that blood sugar can sneak up on us. Most of us have at least one good story about the stroke or the seizure that turned out to be a hypoglycemic event.

O is for overdose (and oxygenation).

If medication bottles are present, does the pill count add up? Is there evidence of drug use at the scene? We discussed alcohol, but don’t forget about other substances that can cause mental status changes. Consider opiates (and check those pupils). Hallucinogens, deliriants and inhalants also produce altered mentation to varying degrees. They account for some of our more unusual mental status presentations.

Also consider an acute hypoxic event. Airway patency, lung sounds and skin should be evaluated early. If the patient is on home oxygen ensure that the supply is uninterrupted.

U is for uremia (or underdose).

Does the patient have a history of renal failure or renal disease? Have they been urinating? Look for signs of increased toxins (mainly nitrogen) in the blood like jaundice, recent fatigue, dehydration, unusual thirst and peripheral swelling.

Some folks also add “underdose” or non-compliance to medication to the U category. Medication non-compliance can contribute to altered mental states, but the true cause of altered mentation will, most likely, be found somewhere else on this list. Is the patient taking their prescribed medications?

T is for trauma.

Could there have been an unreported traumatic event? Could the patient have been assaulted? Could there have been a previous head injury that lead to the current change in mental status? (Think lucid interval.) Your assessment should include a through look at the head as well as a search for causes of occult bleeding in the chest abdomen and pelvis.

I is for infection.

Is there a source of infection? Has the patient been ill recently? Is the patient immuno-compromised? Are they in a high risk category for sepsis such as kids, the elderly, and patients taking chemotherapy and immuno-suppressive therapies? Feel the patient skin. Take a temperature if you have that ability. Pay close attention to the blood pressure. Most of our sepsis patients will show some degree of hypotension before they become noticeably altered.

P is for psychiatric (and poisoning).

This is one where non-compliance to medications can be an important precipitating factor. Does the patient have a history of psychiatric events? Could the current presentation be a simple episode of catatonia or some sort of psychosis? Psychiatric disorders can precipitate some unusual, what-the-heck-is-going-on type presentations. If you feel like you’ve ruled out everything else, consider an acute psychotic episode.

Also consider the possibility of poisoning, both intentional and unintentional.  Consider the environment where the patient was found. Could the patient have had contact with a poison. Consider that ingestion is only one potential route for poisons. Chemicals like organophosphates can be absorbed through the skin and carbon monoxide is inhaled.

S is for stroke (and shock).

Not just occlusive stroke, but anything that might put pressure on the brain. This includes lesions, tumors and spontaneous hemorrhage. Do a thorough neurological evaluation and look for motor deficits in the patients response to stimuli. Note muscular weakness in the face and take a good look at the pupils.

While we specifically addressed hypovolemic shock and septic shock, consider other causes of shock like cardiogenic and anaphylactic shock. Pay close attention to the patients hemodynamic stability and consider an underlying shock state.

AEIOUTIPS takes a little practice. Your first few times working through the acronym will feel awkward. But with a little time and patience, the memory tool can become a trusted friend during some of your more challenging calls. I’ve talked through these nine points out loud with my partner on the way to the hospital when an altered patient us both scratching our heads over what was going on.

While I may not always nail the cause of altered mental status, I rarely find an altered patient who falls outside of the AEIOUTIPS list.

Now it’s your turn. Did you learn the AEIOUTIPS acronym in school? Do you use it during patient care?

Read more EMT awesomeness:

LCES for EMTs

The Ultimate EMS Protocol

The SOAP Reporting Breakthrough

Understanding OPQRST

Learning DCAPBTLS (A Word of Advice)

I imagine it was probably my first Prehospital Trauma Life Support class back in 1990 that I first heard of the three collision rule. Since then, it has remained a useful tool in examining the mechanism of injury after auto accidents. If you haven’t heard of it, please allow me to elaborate.

The three collision rule states that, in any auto accident, there are three collisions that occur and the keen EMT needs to be aware of all three. The next time you walk up to a vehicle accident, instead of imagining two large objects colliding with each other, imagine three separate collisions occurring with each respective vehicle. All of them have implications for the alert EMT.

Collision Number One: The Exterior of The Vehicle Strikes Something

Take a quick walk around the vehicle and consider the elements of Newton’s second law (force is mass times acceleration or deceleration). Ask yourself the questions that apply to that equation. How heavy is the vehicle involved? How fast was it traveling? How fast did it stop? All of these will contribute to the force involved in the initial impact, but speed really is king. Force increases proportionally as the weight of the vehicle increases, but speed has an exponential influence on collision forces.

Several things can give us clues about how fast the car was traveling at impact.

First, pay attention to the posted speed limit in the area of the collision. Cars traveling through a 25 mile per hour residential neighborhood will collided with one fourth the kinetic energy as a car driving through a fifty mile per hour commercial district. Second, look for skid marks and other indications of attempts to slow the vehicle before impact. Third, look at the vehicle itself. Keep in mind the older cars are designed to resist impact forces and newer cars are designed to absorb impact forces while keeping the passenger space intact.

In modern cars, passenger space intrusion and axle displacement are significant findings. Also note airbag deployment within the passenger space and if the headrest height is in proportion to the driver. Now we can move inside the vehicle.

Collision Number Two: Stuff Within The Vehicle Moves Toward The Point of Impact

This includes the vehicle occupants. Everyone inside the vehicle will move in the direction of impact until they are stopped by their seat belts or the inside surface of the vehicle. Both of these options can create injuries. Keeping that in mind, it’s useful to know where the patient was sitting inside the vehicle and whether or not they were restrained.

Also peak around for other heavy objects that may have struck the patient during the crash. Groceries, car seats, tool boxes and the bowling ball from last weeks league game can all become deadly projectiles during a run-of-the-mill vehicle accident. In much the same way, oxygen bottles, med kits and ECG monitors can all add complications to a run-of-the-mill ambulance accident. I digress.

Collision Number Three: Stuff Within The Patient’s Body Strikes The Inside of The Patient’s Body

Excuse my overly technical use of the word stuff, but there’s a lot of stuff inside the average patients body and it all behaves differently when it’s forced to go from fast-forward to stopped-dead. Solid organs like the spleen and the liver fracture and bleed. Hollow organs like the stomach rupture. Vessels like the aorta tear. Lungs rupture or become punctured.

This is all part of the third collision. And if you’ve paid attention to the first two collisions, much of it is predictable. Certainly you can’t predict all the injuries suffered in an auto accident, but you can get pretty good at guessing what injuries you might find based on a thorough investigation of the mechanism of injury.

There you have it. The three collision rule. The next time you walk up to a car accident, count the number of cars and multiply by three.

What do you think? Do you know the three collision rule? Do you think about it? Is it useful? Leave a comment and join the discussion.

Read More Stuff:

Understanding Kinetic Energy and Trauma

Doctors Watching EMS Care on Cameras?

The C-spine Immobilization Controversy

The Ultimate Guide to EMT Vital Signs: Respiration

What Motivates Us Really?

]]> http://theemtspot.com/2010/11/03/the-three-collision-rule/feed/ 5 http://theemtspot.com/2010/06/08/the-ultimate-guide-to-emt-vital-signs/ http://theemtspot.com/2010/06/08/the-ultimate-guide-to-emt-vital-signs/#comments Tue, 08 Jun 2010 20:32:12 +0000 Steve Whitehead http://theemtspot.com/?p=3207 Part 3: The First Rule of Vital Signs

This is probably a good time to bring up the number one rule of vital signs. Remember the movie Fight Club? Everyone knew the first rule of fight club was to never talk about fight club. Now let me give you the first rule of vital signs. Burn it into your memory.

Never lie about vital signs.

Oh, I know. You think you’d never lie about vital signs. You’re an honest person right? Why would you lie about something as silly as vital signs? And yet, it happens…a bunch.

There you are deflating that blood pressure cuff. Everyone’s looking at you, waiting for your report, and you hear . . . . (wait for it) . . . (wait for it) . . . nothing! everyone is waiting. And you did see the needle bounce right around 120 and stop bouncing right around 70. The BP must be normal right? Couldn’t you just make it up and save face?

Don’t do it. It’s hard to admit when you just don’t hear the BP or can’t feel the pulse, especially when you think it’s something you’re doing wrong. It’s easier…and very tempting, to fake it. Don’t do it. You only have to make up incorrect vital signs once to completely blow your credibility.

Report a 120 over 80 blood pressure to your partner when it’s really 60 over nothing just one time and your credibility as a caregiver is shot. Tell the hospital the patient has a strong pulse at 84 bpm when it’s really weak and irregular at 136 bpm just one time and it will be a long time before they trust your hand-off report again. Medicine is harder when your colleagues don’t trust you.

Everyone has had the experience of not being able to feel a pulse, or hear a lung sound or a blood pressure. Practice your vital signs. Take them diligently and then tell the God’s honest truth about what you find.

Now it’s your turn: Have you ever been tempted to lie about the vital signs? Have you ever done it? What happened?

Read more EMS stuff:

Medicine Between The Frames

Beyond the 1-10 Pain Scale

You Can’t Give Away What You Don’t Have

Waiting Is Serving

Self Destruct

I’m not scared of being held accountable for the medical decisions I make. I feel that I tend to make fairly good decisions, thank you very much, but the legal process can be expensive. And let’s be honest…because this is just you and me talking right? Sometimes the right thing to do is far from clear.

In a court of law, everyone is allowed the benefit of months of preparation, and then days and weeks are spent mulling over decisions that were made in real time. In EMS, real time moves faster than you might think. And good, well meaning, experienced paramedics labor to do the right thing.

Such was the case on May 24th 2008, when my friend was called to the home of man who wasn’t answering questions appropriately. Gerald Schlenker, a quirky resident of Arvada, CO, was admittedly a bit drunk when he walked back home and went to bed in his own bedroom.

He awoke to the Arvada police department in his apartment. They were there to arrest his roommate for his role in some sort of disturbance issue and they wanted him to answer some questions as well. He clammed up. He refused to say anything except rude and non-sensical statements. That’s when my buddy got involved.

Have you ever been in this situation before? Someone is drunk in their own home. They may or may not have initiated a call for help. Now they want to stay home. What are our options?

Frankly I can see this guys frustration. You find your way safely home, you go to bed and you wake up to a bunch of police officers in your home, wanting answers to questions about who you are and what you’re doing. I could see being pretty pissed off.

I can also see my friends vantage point. (All to well.) The guy won’t answer basic orientation questions. How can you possibly allow him to refuse your care? How can you document that he’s competent and able to care for himself? Is he really safe at home? Where does your need for documentation end and his human rights begin?

My friend opted to transport. If I was in his shoes, I could easily see myself making the same decision. Then Mr. Schlenker got downright belligerent. He eventually needed to be restrained. And then he was sedated. At the E.R. he was eventually granted a psychiatric evaluation. He sobered up, cooperated, and was released the next day. Then he was sent a $6,000 bill for his troubles.

As you might imagine, Mr Schlenker is suing everyone involved, the police department, the hospital, the ambulance service, and even my friend, the paramedic. He made a decision that he felt was in the best interest of the patient and now he’ll need to defend his actions in court. He’s a great paramedic. I’m certain he gave Gerald outstanding, compassionate care. He did everything to ensure his safety and well being. Sometimes you just can’t win.

Maybe it’s my king-of-my-castle mindset, or my mid-west style patriotism talking here, but I’m inclined to give people a lot of leeway when it comes to allowing them to stay in their homes when they choose to stay. Removing people from their homes against their will sits poorly with me.

Sometimes I still do it. It’s my job. But I never like it.

Regardless of their medical condition, the potential for a dangerous outcome, their level of intoxication, or even their willingness to cooperate, I feel like people have the right to make bad decisions in their own homes. And it’s not our job to always fix it. I feel bad for everyone involved in this mess.

What about you? How would you have handled this case. What do you use to guide your decisions when you’re trying to decide if someone can stay home on their own?

Want More Articles Like This One?:

Regarding The Duty To Act

What is The Duty to Act?

What is The Good Samaritan Law?

The Oklahoma State Trooper vs. EMS Mess

Wrong Medicine

As much as we practice this skill in EMT class, I often wonder why so many EMT’s have such bad head-to-toe skills out on the street. It seems that, once we get out on the street, the systematic, thorough head-to-toe assessment falls out of favor and quickly gets replaced with the faster, more direct focused assessment.

That works just fine most of the time. If it didn’t, I figure it probably wouldn’t be such a universal phenomenon. (For the record, have you ever worked somewhere where this wasn’t the case? Neither have I.) The downside is that when the patient arrives who really needs a, honest-to-goodness, rapid, complete head-to-toe, we’re not up to the task.

I happen to believe that patient assessment skills are one of the defining qualities of a talented EMT. Here are seven tips to keep your head-to-toe in top form.

1. Do head-to-toe assessments frequently.

I mean more frequently than you’re doing it right now. You have a lot more opportunities to do a a good head-to-toe than you’re currently taking advantage of right now. Drop the surprised expression. This is just you and me talking here right?

That infant in the car seat involved in the fender-bender could have used one. That trip and fall at the mall would have been prefect too and so would that dude punched in the bar fight. You let them all go without a top-to-bottom physical exam. The more you do head-to-toe exams, the more comfortable and efficient you’ll become.

2. Be systematic.

It’s called a head-to-toe for a reason. No, that doesn’t mean that you need to start at the head every time. (In fact, with kids, I recommend starting at the feet.) But you do need to have a system and stick to it. If you make up your physical exam each time you do it you’re never going to be smooth. When an emergency is in full-swing, the assessment won’t come naturally.

People tried to teach me this lesson for a long time and I don’t know why I was so slow to learn it. I guess it just seemed silly to force myself to do the assessment the exact same way every time. I’m glad I finally relented. Now I understand. If you want to be efficient when it counts, you have to be systematic.

3. Pay attention to the patient’s facial expressions during your assessment.

Sure we ask the patient if it hurts, but you’ll pick up on a lot more if you pay attention to the patients face. Are they distressed or relaxed? Are they paying attention or distracted? Do they wince or grimace during palpation? There are many reasons why a patient might try to conceal their discomfort and if you are in the habit of only looking at the body part you’re checking, you’re going to miss some stuff.

4. Interact with the patient.

I don’t just mean, breathe deep, does this hurt, yada, yada. That’s the patient interview. But it isn’t real interaction. Talk to people while you’re assessing them. Family doctors have mastered this skill, and for good reason. There’s a wealth of patient assessment information to be gained by just talking with folks about what happened, where they were going and whatever else is on their minds.

You don’t need a fancy mental status exam to figure out if people are oriented and responding in context. Just talk to them. If their brain isn’t working right you’ll figure it out.

5. Visualize the structures beneath the skin.

This requires you to know your anatomy. If you’re palpating parts of the body and you can’t visualize the structures beneath the skin, go back to your anatomy text book or try to find a cadaver lab to attend.

It’s a worthwhile skill to be able to visualize what lies beneath the patients skin and it’s essential when we are calculating the possibility or probability of injury and developing a differential diagnosis.

6. Feeling, really feeling, is harder than you might think.

Of course, we feel the patients body. Palpation is feeling. What else would we be doing? Actually most of what’s going on is looking and asking. Things that we see like bruises and abrasions are rarely missed in a proper physical assessment. Pain and tenderness is also pretty easy to pick up on. Push, “ouch”, got it.

But things that we need to feel. Things like crepitus or masses, or fever or coolness or rigidity. Those things tend to get missed. we miss them because it’s easy to go through the motions of palpation, but it requires some mental energy and practice to really feel for abnormalities.

It’s also something we never really get to practice until were doing real-deal patient assessments. In class we get in the habit of looking and pushing but you can’t really feel abnormality on a mannequin. They feel hard and plastic every time. When you’re palpating a human, focus on what you’re feeling.

7. Be confident.

Have you ever watched an ER physician do a physical exam? Pay attention the next time you get an opportunity. Watch not only the types of assessments they do but the manner in which they move from one assessment to the next, interacting with the patient, describing the needed behaviors or responses.

ER physicians do thousands of patient assessments and it shows. They don’t need to think about the next step in the process. They just do it. It’s the same way a short order cook doesn’t need to think about the ingredients in your Denver omelet. It’s the same way a professional baseball pitcher doesn’t need to think through the steps to throw a slider. They have reached a level of unconscious competence.

When you’re working on your head-to-toe technique, strive for that level of unconscious competence. Where you are confident in your ability because you know what comes next without ever needing to think about it. At that level of ability you can really focus on what you’re seeing, feeling and hearing.

I said it at the beginning but it bears repeating. Your physical assessment skills are one of the defining qualities of your patient care ability. When I’m evaluating a new EMT or paramedic, one of the first things I want to see them do is perform a complete head-to-toe assessment.

Performing that skill well, with calm confidence, is one of the hallmarks of a good EMS provider. It is an essential, foundational skill that speaks volumes about your ability. Could yours use a tune-up?

Now it’s your turn: Have you ever known a really good EMT who couldn’t do a near-perfect head-to-toe assessment? Have you ever known a really bad one who could? What are your tips for mastering this skill? Other readers would like to know. Leave a comment and help make this post even better. 

Read More Goodness:

Test For Unconsciousness: The Hand-Drop

Five Big Trauma Scene Mistakes You Can Avoid

5 Assessment Findings That Should Concern You

The EMT Code of Ethics

Beyond The 1-10 Pain Scale

One of Scott’s observations is that comic books require imagination on the part of the reader because, in all great comic books, the action occurs between the frames. The artist only shows you snapshots of action and dialogue. Most of the story takes place in our heads. The real story is the stuff that we invent that happened in-between the frames.

Medicine works in much the same way. We assess, we ask our questions, we do our head-to-toe and we make a guess (educated) about what’s going on. Then we make a change, and the medicine begins, after we make the change, not before.

Then we do the in-between stuff. Loading the patient on the pram, shoring up the splinting, carrying the bags back and forth, making a phone call to the doc. And the medicine works … or it doesn’t.

And then we start the next frame. The action starts all over, but make no mistake, the medicine happened while we were doing other things. Just off the boarder of the frame.  Between one action and the next, while were busy doing the in-between-stuff, the medicine happens.

Don’t miss it.

Now it’s your turn: Do we forget to focus on the medicine that happens in-between our interventions? Is it important to remember that the medicine happens in-between interventions or is it just a matter of semantics.

Related Articles:

The Art of The Pulse Check

The Art of The Nasopharyngeal Airway

Understanding OPQRST

Beyond the 1-10 Pain Scale

The Ultimate EMS Protocol

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