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

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

I’ve gone live with the book and newsletter sign up and it appears that everything is running smoothly. I’ve already had a half dozen sign-ups and the link has only been posted for a few minutes.

Thanks for your patience. This writing project took me nearly six months to finish. I had an idea of what I wanted this book to be and I wasn’t willing to stop until I’d succeeded.

The result is The Non-Conformists’ Guide to EMS Success. This is no pamphlet or power point slide show. This is 48 pages, almost 16,000 words, and chapter after chapter of compelling ideas designed to challenge the way you think about your job, your leadership, your life, and your role in EMS. And it’s all free.

If you’re ready to stop listening to me talking about it and get the book for yourself, just click the newsletter sign-up at left. The EMT Spot practices a strict, double opt-in, anti-spam policy. We’ll never reveal your e-mail to anyone, ever.

You’ll receive an e-mail confirming that you really did sign up for Splatter and the e-book. Once you click the confirmation link you’ll received your welcome edition of Splatter and the .pdf version of the e-book will be attached. It’s as simple as that.

The newsletter will also have an opt-out link at the bottom if you’d rather not be on the newsletter mailing list. (But I hope you’ll decide to stay)

I also hope that after you’ve read the e-book, you’ll come back here and post a comment, or send me an e-mail, letting me know what you thought about it.

I look forward to your comments, I look forward to providing you a behind the scenes look at the web site in the monthly newsletter and I look forward to continuing to provide you with quality content right here on the blog. Thank you for stopping by.

Now it’s your turn: Will you be signing up for the e-book and newsletter? Why or why not? If you’ve read the book, what did you think? Leave a comment before you go.

My first E-book is scheduled for release on January 21st, one week from today. The e-book will be free and it will be available right here at The Spot.

The Book is called The Non-Conformists Guide to EMS Success. This book is the culmination of two decades of EMS experiences, mistakes, failures, trials, and errors that lead to my ultimate success. My goal was to write something that would be useful to EMTs at any stage in their career. And I didn’t hold anything back. This is my road map to finding true success and fulfilment in EMS work.

I started at the beginning and kept typing until every ounce of useful information was on the screen. Over 15,000 words and 50 pages later I closed the largest writing project I’d ever undertaken. And now you can have it for free.

The book release will also coincide with the launch of Splatter, a brand new bimonthly newsletter for regular readers of The EMT Spot. Splatter will be the behind-the-scenes, insiders guide to The Spot. You’ll get the e-book and the newsletter all in one go. And it’s all going to happen right here. So mark your calendars. I’ll see you back here in a week for the ribbon cutting and the cake.

I’d like to teach you how to take a pulse in three seconds or less. Yes it’s possible.

I am, quite possibly, about to contradict everything you learned about taking a patients pulse in your EMT class. Hear me out on this one.

In general, I think we overemphasize the importance of coming up with a set of numbers that represent the patients vital signs and we underemphasized the importance of placing the patients vitals in context for their condition. The pulse is a prime example of this dynamic at work.

The patients pulse holds a wealth of clinically significant information. The exact heart rate isn’t one of them. Sometimes, we get this misconception lodged in our brain that the purpose of feeling the patients pulse is to determine how many times their heart is beating each minute. We will dutifully devote 15 seconds, 30 seconds … yes some even advocate taking a full minute to make sure this number is perfectly accurate.

I disagree. You can determine everything you need to know about the patients pulse in three seconds and then move on. The next time you kneel to take a patients pulse, consider these four, clinically relevant findings instead of staring at your watch.

1. Estimate the heart rate.

That’s right, just take a guess. The more you practice this, the better you’ll get. You should be able to guess the patient’s heart rate to within four beats-per-minute in either direction. That’s as close as you need to get. Get in the habit of grabbing a pulse and estimating the rate before you look at the monitor or count it off a watch. You’ll be surprised. This isn’t as tough as it might seem.

2. Is the patient’s heart rate to fast or to slow?

Start thinking like Goldilocks. You know … from the nursery rhyme? Everything was either too much or too little or just right. Once you have an estimated idea of the pulse rate ask yourself, “Is that too fast for this patient, too slow for this patient or just right? Knowing whether the pulse is too fast or too slow in the context of this particular patient is much more important than having an exact number.

3. Is the patients pulse strong or weak?

Imagine the heart as a pump (it is) sending a wave of pressure through the arteries and out to your gloved fingers. Is it a strong pump or a weak one? Does the pulse bound strongly or is it thready and weak? This is significant.

A quick note on weak pulses; don’t spend to long searching for a pulse you can’t find. We tend to doubt ourselves when we are unable to find a pulse so we keep searching, and searching … and searching. If you can’t feel a pulse, check quickly at the brachial artery and then grab your blood pressure cuff.

If you find that the blood pressure is adequate you can always come back and search around for that pulse, but don’t delay the continued assessment of a possibly hypotensive patient to search for a pulse.

4. Is the patients pulse regular or irregular?

Does the pulse have a nice regular cadence to it or does it occur irregularly. An irregular pulse will present in gallops and pauses. It can be subtle or obvious. In some cases, an irregular pulse is not clinically important finding. In some cases it could be medical emergency. Note the regularity or irregularity of every pulse you check.

What I’d really like you to take away from this is that the exact heart rate is pretty low on the clinical significance scale. We tend to spend far too much of our time, energy and focus on obtaining a highly accurate heart rate and not enough time or focus on the things that are very significant about the patients pulse. Is it too fast or too slow? Is it strong or weak? Is it regular or irregular? There will be time later to get the heart rate nailed perfectly. And if there isn’t … it probably wasn’t that important anyway.

So what do you think? How much time do you spend taking a patients pulse on scene? Do you agree or disagree with my thoughts on the importance of that task? When is it very important to have an exact heart rate? Is it ever? Leave a comment and let me know.

Related Articles:

 The Art of The Nasopharyngeal Airway

Remembering The Glasgow Coma Score

Understanding Combative Head Injuries

Describing Pain

Six Techniques to Nail The IV Every Time

In other words … it’s a great subject for The Spot.

Like many controversial assessments and treatments, the sternal rub (sometimes referred to as the sternum rub) got its bad-boy reputation more from its misuse than from its own shortcomings. Never-the-less, the technique does have its shortcomings.

Like so many other tools, it has its place when used appropriately and it has its potential for misuse. So let’s make sure you understand its uses and limitations.

If you’ve never encountered this technique, the sternal rub is a test for unconsciousness. It’s a popular form of painful or noxious stimuli designed to illicit a response from a conscious or semi-conscious person. Establishing an unresponsive patients ability to respond and remove noxious stimuli is perfectly medically appropriate.

Note that on your Glasgow Coma Score, establishing  best eye response and best motor response both require the ability to administer and observe the patients reaction to pain. Having said that, I’m not the biggest fan of the sternal rub. i think there are other more appropriate tests like the face flick and the hand drop that, when done correctly, render more valuable information.

To perform the sternal rub, the care provider makes a fist and places his knuckles against the patients mid-sternum. Applying firm downward pressure the provider then rubs up and down across the sternum. To the uninitiated, this is surprisingly uncomfortable. With even a moderate pressure, the sternal rub is unbearable to most folks.

On the surface (pun intended) the stenal rub seems simple enough. Fairly benign body area … fairly simple technique. What could be the problem?

There are several:

We tend to overuse it.

Recall the last time you performed the sternal rub and the patient did not respond at all? What was your reaction? Did you begin aggressive airway management? Did you call for rapid transport? Or .. did you do it harder? … And then maybe a little harder? And then one really good one just for good measure?

And then the nurse at the hospital did the same thing. And then the intern did the same thing. And then the resident and on and on. And by the time the patient regained consciousness they had a big bruise and a sore chest for the next week. We overuse the technique when we think people should be responding but they don’t. Perhaps one reason we overuse it is because we know …

Some people don’t respond to it.

Especially people who are drunk or sedated. People who’ve had it done to them multiple times and the odd person who just has a really insensitive sternum. Because of these outliers we tend to keep trying the technique just a little more aggressively to see if this isn’t just one of those people who doesn’t feel it that much.

Some reports state that many patients don’t reposnd until pressure has been applied for 30 or more seconds. I’m not comfortable with applying the rub for that long or that hard to see if I can illicit a purposeful movement. That makes the results difficult to interpret.

For the record, any painful stimuli that leaves marks on the patient is inappropriate. If the patient arrives at the hospital with marks from your assessment, you did it wrong. No excuses.

It’s not a first line technique.

To many folks walk up and start in on the sternal rub as their first line assessment of unresponsive patients. No gentle shake and shout, no face flick or loud verbal stimuli. Just one good sternal rub. If the patient wakes easily, your patient rapport is pretty much shot after a good sternal rub. This is also a good way to get hit or grabbed because …

It places your arm in a bad spot for combative or dangerous patients.

It’s tough to do a sternal rub from above or out of the way. You pretty much have to offer up your whole forearm to the patients grasp. Beware and be ready to defend yourself if you come out of nowhere with a good hard sternal rub.

So how do we do it properly?

If you rub your knuckles firmly across your sternum you’ll discover that this move hurts. You don’t need to lay into someone with everything you’ve got. Give a good firm rub and then be done with it. Pay attention to the patients hands. For your own safety and because that might be the only response the patient is able to make.

I’d suggest keeping the sternal rub farther down on your assessment checklist. Remember to use less aggressive forms of stimuli first (i.e. noise, shaking, flicking, pinching.) Don’t just walk up to some poor dude and start in on him with this move.

The appropriateness of the sternal rub lies entirely in the hands of the care provider using the technique. When dons properly by someone who understands its benefits and limitations, it can yield valuable information. When done poorly, it is at best useless and at worst abusive.

Hopefully you’ll always use the sternal rub with caution, good intentions and respect for the patient.

Related Articles:

Test For Unconsciousness: The Face Flick

Test For Unconsciousness: The Hand Drop

Remembering The Glasgow Coma Score

Understanding Combative Head Injuries

Describing Pain

What Is Blood Anyway?

We painted the perfect picture for you in your cardiac emergencies lecture in your EMT class. The pain felt like a pressure. It was brought on by exertion. It radiated to the left arm and through to the back. Sometimes, in your EMT skills stations, we would get fancy and have it begin at rest and radiate to the jaw. Just trying to keep you on your toes after all.

All this stuff is good to know. But we may have done you a disservice. You may be walking around with the idea that you can do a quick OPQRST and a SAMPLE and walk away with a fairly good feel for whether or not your patient is having a heart attack. You may be dead wrong.

What we may not have told you was that a large percentage of your patients suffering acute myocardial infarction won’t look anything like this. Atypical cardiac chest pain, those folks who have heart attacks but don’t quite feel like they’re supposed to feel, are actually very common. Common enough that we may need to think of a new name for them. Research says that the atypical folks may be a whole lot more typical than we think.

Did you know that the patient who is having a true myocardial infarction is 10% more likely to have pain radiate to his right arm than his left? Wrap your brain around that one.

It gets worse:

• 26% will experience shortness of breath as their primary complaint.
• 23% will complain of a burning sensation similar to indigestion.
• 6-9% will say the pain is positional or pleuritic. (Associated with respiration.)
• 5% will describe the pain as sharp and stabbing.

And when you’re done adding up all of those atypical findings, consider this:

A full 33% of acute myocardial infarction patients will have no pain at all.

You read that right – 33%. One out of every three heart attack victims don’t feel any pain. They have syncopal episodes or they have palpitations. They may get dizzy, feel weak and even fall down. They may complain of unusual sweating or an inability to catch their breath or vague nausea. But they won’t feel pain. You’ll need to figure out that their having an acute cardiac event all on your own, without the help of the single most telltale sign in the book.

The chances of having a painless heart attack increase dramatically with age. Diabetic are particularly prone to painless MI’s and females tend to have them more often than men.

When you add it all up, the atypical chest pain patients may very well be more typical than the presentation we described in your EMT scenario. The next time you encounter an acute cardiac patient with exertional chest pain that feels like a pressure and radiates to the left arm, you may want to think to yourself, “Interesting cardiac presentation … but not very typical.”

“Symptoms Other Than Chest Pain …” Circulation, 111(24) e435-e437, 2005

“Prevalence, clinical characteristics, and mortality …”  JAMA 2000 Jun 28;283(24):3223-9

“Acute Chest Pain in The Emergency Room” Arch Intern Med. 1985;145(1):65-69

Related Articles:

Wrong Medicine

Beyond The 1-10 Pain Scale

Understanding OPQRST

Quality Assurance In EMS

For sure one of the more useful acronyms I’ve learned is OPQRST. I learned it back in EMT school in 1989 and I’ve been using it ever since. I can’t imagine how many times I’ve gone through these letters in my mind while meandering through a subjective assessment with a patient.

This is an acronym that has stood the test of time, which is saying a lot in the word of emergency medicine. Considering everything that has come and gone in the last three decades of EMS evolution, the most remarkable thing we can say about OPQRST is that it has endured.

Today lets dive a little deeper into the nature of OPQRST questioning. What does OPQRST mean? When should we use it? What kinds of questions should you be asking to get the information we’re looking for and where does the OPQRST standard fall short of providing us with a complete picture of a patients pain.

Let’s start with when we should pull OPQRST out of our toolbox.

The mnemonic was created to address patients having pain of a non-specific origin. I mean to say that if you’re not sure what’s causing the pain, pull out OPQRST and give it a whirl. The patient has lower right quadrant pain? Let’s do some OPQRST. The patient has a twisted right ankle? We can keep the OPQRST questions in the bag.

There are some non-pain related complains that can be addressed with OPQRST as well. Shortness of breath fits the bill so well that the National Registry medical skill sheet uses OPQRST in the respiratory column as well as the chest pain column. Nausea and dizziness are two other complaints that we can apply to OPQRST as well. (We can probably skip the Q.)

Before we jump into what the letters mean I’d like to offer a warning about the words associated with the acronym. Like many acronyms, OPQRST has some fancy, pretty words attached to it. The words are a prompt in your head. They aren’t the best words to use when talking to your patient.

I get a bit annoyed when I hear caregivers talking to their patients about onset, radiation and provocation. For your patients sake, re-frame the words of the mnemonic into something easier to talk about. Your interaction show feel like a conversation, not a scholarly dissertation.

OK, let’s get to it:

Onset. We want to know what was happening when this all started. What was the patients physical state and what was their emotional state when this all began? Does the patient feel the pain is associated with the thing they were doing? This also gives us clues as to how long the patient was willing to endure the pain before calling. Also try to address how sudden the pain came on. Was it a rapid onset or was it gradual? This will help us wrap our brain around chronic vs acute presentations.

O – questions: “When did this all start?”, “What were you doing?”, “How were you feeling right before this started?”, “How many hours ago was that now?”, “Did it come on suddenly or gradually?”, “Do you think this pain could be related to lifting all those tires, mowing your lawn, fighting with your wife, sitting on that church pew?”

Provocation / Palliation. We want to know what makes it better or worse. What types of external factors have worked to alleviate the pain (Palliation) and what things have made it increase. This includes our palpation of the region.

P – Questions: “Has anything made it feel better since it started?”, “What makes it feel worse?”, “Does it hurt more when I push on it?”, “Does it hurt when you take a deep breath?”, “Does leaning forward like that make it feel better?”

Quality. We want to know how the pain feels. Of all the OPQRST questions, this one probably gives the patient the most trouble. Some folks just really struggle to come up with words to describe how the pain feels. This is when it becomes easy to lead the patient and we have to take care not to do that. If you give examples, try to give to opposite alternatives.

Q – questions: “What words would you use to describe this pain?”, “Can you tell me how it feels?”, “Is it more sharp or dull?”, “Would you describe it as a pressure, an ache, a stabbing pain, a burning pain, a tearing pain?”, “What would need to happen to me to make me feel that pain?”

Radiation / Region. We want to know where it is and where it goes. I tend to start this line of questioning by picking up the patients index finger and asking them to point directly to the pain. This gives a good location and also gives me some insight regarding if the pain is specific or in an area. Then I ask if it stays there or goes anywhere else.

R – questions: “if you could point with this finger, where is the pain right now?”, “Has it always been right there?”, “Where else does it go?”, “Does it move anywhere?”

Severity. We want to know how bad it is. I recommend using the 1-10 pain scale to have the patient rate their pain. It’s simple and no more or less accurate than any other pain rating scale. I described the 1-10 pain scale in some detail a few weeks back. Keep in mind that the severity scale also allows you to trend where the pain has been and recognize if your pain management strategy is working.

S – questions: “On a scale from one to ten, ten being the worst pain you have ever felt and one being a mild headache, what number would you give this pain you’re having right now?”, “What number was it when it started?”, “What number was it when it was at its worst?”

Time. When want to know when the pain started and if it has been constant, colicky or wave-like. You may have addressed the exact time the pain started in your onset questions. If your still fuzzy, nail it down here. Then try to get an idea of the pains progression. Has it been constant or irregular. If it is irregular does it come in a predictable pattern or are the waves random?

T – questions: “Do you know exactly when it started?”, “What TV show was on when this started? – Were you at the beginning or the end of American Idol?”, “Has the pain been non-stop since then or does it come and go?”

There are some additional things to keep in mind when using the OPQRST tool.

First, recognize that each letter represents a concept regarding the nature of a patient pain or symptom. Sometimes we teach OPQRST in away that makes it seem like it is a list of six questions. It’s not. It represents six ideas that you need to explore. When you start at O, don’t stop asking onset type questions until you feel like you have a firm grasp of the onset of pain event. When you get it, move on.

Second, there are two halves to every conversation. After you’ve asked the question, stop and listen to the answer. If you were talking with this person over diner and you asked a question, you wouldn’t ask it and then immediately reach for the mashed potatoes and tell your brother to turn on the UFC fight. (OK, maybe if they were really good mashers and Chuck Liddel was fighting.) But we do this to the patient all the time. Ask, listen, repeat.

Last, remember that OPQRST doesn’t always give us a complete picture of the pain. There are a few other considerations you might want to add after you’ve run out of letters. Here are a few holes you might still want to plug up after the OPQRST line.

• Consider if there are any other associated symptoms related to the pain or symptom. Chest pain is one animal, chest pain with associated shortness of breath is a whole other creature. Are there other symptoms we need to consider?
• A huge, very telling question that often gets left out is, “Have you ever had a pain like this before?” Your patients previous experiences with similar pains can be very helpful.

What else do you throw in with your subjective pain evaluations? This is a huge topic and I’m sure I haven’t covered it all. What other questions have you found useful?

Related Articles:

Beyond The 1-10 Pain Scale

Learning DCAP BTLS (A Word of Advice)

Describing Pain

Understanding Combative Head Injuries

The hand drop test is considerably more well known than its cousin the face flick and it remains a fairly reliable, though somewhat controversial test.

There’s a reason why the hand drop test is so well known. It tends to work. It’s a clever and reliable way to force a patient to make a decision and reveal their true mental status.

When done properly it’s harmless and does not require forcing pain or noxious stimuli on the patient. It also has the advantage of  being appropriate to perform in front of family and loved ones. Unlike the face flick which is a bit to obnoxious for public consumption, the hand drop can be performed anywhere and looks like a fairly standard neurological test. If you don’t have this one in your tool box yet, it’s time to add it. If you do know it, let’s review it. There are some subtle elements to doing the hand drop test accurately and safely.

What we’re going to do with the hand drop test is test the patients muscle tone and cognitive ablitity with one move. Without warning, we gently pick up the patients hand and hold it above their face. Without delay, we drop it. If the patient were truely unconsious, the hand would fall and strike them in the face. Most likely on the mouth or chin. We’re not going to let that happen, but the patient doesn’t know that.

You see, the instant that we drop the hand, the patient has a decision to make. Patients don’t know what their hands are supposed to do when dropped over their face and the idea of striking themselves is instantly unappealing. But what to do instead? The resulting dilemma is both revealing and, often, hilarious. The amusing nature of watching a conscious patient decide what to do with their falling hand is certainly part of the popularity of this exam. 

 Now for a few of the finer points of technique.

One mistake that can lead to inaccurate results is allowing the patient’s hand to hover too long over the face before dropping it. Remember that the success of the test is dependant on the patient not having time to decide what to do with the hand. If you allow them to ponder what should happen to their hand before you drop it, you’re going to get inaccurate results. Don’t lift the hand until you’re ready to drop it.

The next error is not protecting the patient face. The hand drop test is indeed a test. If you’re already certain that the patient is conscious then there’s no need to do this. If you’re uncertain, then you should be protecting their face. As you lift the patients hand with one hand, place your other hand just above their face to protect it. It’s embarrassing to bring a patient in with a fat lip or a swollen nose and have to report that you did it playing “stop hitting yourself” with the unconscious patient.

It’s also a good idea to protect the patients elbow as well. Get ready to grab their arm because it should fall flaccid at their side if they are unconscious. Make sure the elbow isn’t on a collision course with something like a pram railing.

I find the hand drop remarkably reliable on all but the quickest thinkers. Conscious patients who pass the hand drop test tend to be folks who’ve played the game before and know that it might be coming. Some folks just become darn good at feigning unconsciousness. It’s a sad but true fact of emergency care.

And while this last part should go without saying, I’m going to put it in here anyway. No test is completely accurate regarding level of consciousness. People presenting with altered mental states and verbal unresponsiveness need to be treated as unconscious regardless of our suspicions based on tests such as these.

If you develop the habit of blowing off your patients because they fail tests like the hand drop and the face flick, you’re bound to get caught with your proverbial clinical pants down sooner or later. A bad day indeed.

What other tests do you find useful in determining level of responsiveness?

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