Understanding OPQRST

After my post/rant about the overuse and misuse of the DCAP BTLS TIC acronym in EMS education, I was asked the question, ” Well, are there any acronyms that you do find useful?” And the answer is an emphatic yes. Some acronyms make for useful mnemonic devices to help us recall needed information in stressful situations. Despite my strongly worded warning about the use of acronyms, I think there are several good ones that have valid clinical uses.

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.

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Test For Unconsciousness: The Hand Drop

After I wrote a recent article on the benefits of the face flick for assessing level of consciousness, I received a string of questions and commentary on the effectiveness of another, more well known assessment for unconsiousness - the hand drop test.

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.

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Learning DCAPBTLS (A word of advice)

I first heard the BCAPBTLS acronym sometime around 1998 while helping a group of EMT’s practice their skills. I hadn’t been involved in EMT education for several years and I had missed the whole inception of the DCAPBTLS acronym. Dutifully, each aspiring EMT moved from the head to the neck, shoulders, chest and abdomen. Each student verbalized their assessments as they went along and sounded off the acronym in turn.

“I’m exposing the chest and looking for DCAPBTLS.” “I’m checking the abdomen for DCAPBTLS.” On and on it went until I finally interjected, “What is this word you all keep using?”

“What word?”

“That word. The Dee Cap something.”

“Oh yeah.” They chimed in and began explaining the purpose of the DCAPBTLS acronym. If I remember correctly, there may also have been a “TIC” component added on to the end as well. If there was, the TIC part has been lost to education history. The students explained that DCAPBTLS was an acronym that was designed to help them remember the various abnormalities that they were looking for during the assessment. Then the funny part happened.

Collectively the students tried to recall all the elements of the acronym. “Deformity, contusions … uh … abrasions.” The room fell silent. “Uh … the T is tenderness.”

“Don’t forget bruising.” Another student chimed in. “Oh, yeah. Bruising.”

By the time the students collectively produced all eight elements of the acronym, several things were clear. The eight elements of DCAPBTLS was not one of them. Before we get in to that, let’s set the record strait. DCAPBTLS stands for:

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Test For Unconsciousness: The Face Flick

Sometimes, when we get on that outer boundary of established medical practices we start running in to controversy. As an author, and a bit of a non-conformist, I love controversy. One area that falls in the gray realm of medical assessment is testing for unconsciousness. This is a concept familiar to all who work in emergency services and rarely considered by the lay public. I’ll explain.

When we encounter a person who is not responding to us there are several possibilities.

1.) They may be unconscious

2.) They may be semi-conscious

3.) The person may be sleeping

4.) They may be fully conscious and feigning unconsciousness (for various reasons)

We treat all patieint who refuse or are unable to respond to us with a high index of suspicion for injury or illness, but it’s helpful to try to get an idea where the patient actually is mentally. Are they here and not responding to us, or are they just not here?

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What Is Nystagmus?

When we think of testing for nystagmus, medical personnel and lay people alike, we tend to think of the horizontal gaze nystagmus test performed by police officers as part of the standard field sobriety test (SFST). It’s true that the police have taken this useful neurological exam and put it to good use to identify folks who may have had to much to drink. There are other good uses for the nystagmus test as well.

I use the horizontal gaze nystagmus test as a part of the basic neurological exam that I do any time I’m uncertain of how well a patients brain is talking with their body. Head injuries, altered mentation, syncope, dizziness and headaches are some of the common complaints that make me want to check out how well the patients brain is doing its job. So this test gets pulled out of the tool box frequently. But what is nystagmus anyway? How do you really test for it and what does it tell you when you find it?

What is nystagmus?

Imagine that I took a large drum and I painted it white with black stripes running evenly down it. Then I set the drum on an axis and spun it slowly in one direction. As you watched the drum your eyes would focus on a black stripe and follow it across the surface of the drum until the stripe moved out of visual range. Then your eyes would jump backward to acquire a new stripe and follow it. This repetitive cycle of smooth eye pursuit interrupted by fast twitches (saccadic movement) is what we call nystagmus.

This peculiar tracking of the eye can be induced by spinning in a chair, riding on a roller coaster or observing a spinning object like in the example above (AKA Opticokinetic nystagmus). It can also be caused by a wide variety of medical and pharmocological conditions. Most causes of nystagmus point to an abnormal condition within the nervous system. It is a physical finding that calls us to pay attention and look deeper.

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EMS Response To Sexual Assault

A Guest Post By: Jimmy Futrelle

The EMT Spot would like to welcome Jimmy Futrelle to our guest post roster. Jimmy s a Paramedic hailing from Scurry County Texas. Jimmy has been responding on calls long enough to remember the Lifepack 5 and using D50 as a diagnostic tool. His unique background working for private and public EMS as well as for local law enforcement makes him uniquely qualified to teach on the subject of sexual assault.

This detailed guide to responding to these challenging calls is well worth reading. I sincerely thank him for this contribution.   

Responding To Sexual Assault

Introduction

Sexual assault is possibly the most devastating form of assault perpetrated on another human being.  The legal definition of sexual assault is “any genital, anal or oral penetration by a part of the accused’s body or by an object, using force or without the victim’s consent.”

The U.S. Department of Justice’s National Crime Victimization Survey reports that over 500,000 women and approximately 49,000 men report being sexually assaulted each year. It is estimated that 1 in 5 women will victims of rape by the time they are 21 years of age.  61% of reported rape victims are less than 18 years old. 1 in 7 women will be raped by their partners. Only 16% of rapes are ever reported to the police.

Let us not confuse sexual assault with sexual abuse. Sexual abuse is repeated instances of sexual assault occurring over a period of time, generally by a person familiar to the victim. Whereas this crime is no less devastating, we are going to focus on the act of sexual assault.

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Five Assessment Findings That Should Concern You

Did you ever watch the old Star Trek TV show? No of course you didn’t, but this is just you and me talking here right? OK, remember when something would threaten the ship. The captain’s first response was to say, ”Go to red alert.” or “Set condition red.” and the lighting would change and a little alarm would sound. That funky shaped light on the front console would start pulsing red. Everyone knew to treat the situation with importance.

I don’t know about you, but I have a list in my head of assessment findings that cause me to shift mental gears into condition red. I don’t need to say anything overly dramatic, but everyone on who works with me can tell when I’ve switched gears to condition red.

For one thing, I start moving just a bit faster than my usual casual pace. I delegate tasks in a laundry list fashion. “I’m going to need an O2 mask. Lets get the pram to the door and bring a stair chair up here. Jesse strip me a line in the rig and check the status of Swedish ER.” The patient may not know the difference, but people who work with me can tell that I’ve set condition red.

Here are a few of the assessment findings that send off alarm bells is my head.

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Rapid Diagnosis: Pinpoint Pupils

Abnormally constricted or “pinpoint” pupils are a great finding for our rapid diagnosis series. There are many things that can cause the pupil to abnormally dilate. Very few things will make the pupil abnormally constrict. Constricted pupils are a doorway to a very short list of ailments and with a bit of background you should be able to hang your hat on one fairly quick.

How do we assess for “pinpoint” pupils?

Recall that the pupil should be mid-range and reactive under normal lighting conditions. When subjected to bright light, the pupil will constricted to reduce the volume of light entering the iris. In darkness the pupil will dilate to allow as much ambient light in as possible. Pupils smaller than 2mm in diameter under normal lighting conditions can be considered “pinpoint”. Any pupil that responds to changes in lighting conditions with 1mm of movement or less can be considered minimally reactive or nonreactive.

To assess for pinpoint pupils we need to subject the pupil to darkness by asking the patient to close their eyes or covering the patients eye. When we return the light source to the pupil we expect the pupil to be larger and rapidly return to its original size. If the pupils remain <2mm in diameter through the changing light conditions we have a “pinpoint pupils” finding. The fancy medical term for this phenomenon is abnormal miosis.

If the patient has bilateral pinpoint pupils consider the following possible etiologies:

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Describing Pain

Take a moment to increase your pain vocabulary

It’s been said that the Inuit have over a hundred words to describe snow. Linguists use the number to explain something significant about how we see the world. The Inuit and Eskimo encounter snow much more frequently than the average Spanish or English speaker, therefore they would describe it with more words. But it also gives insight into our life experiences. When an Inuit sees snow, he sees more than you or I do. Same snow, more meaning.

And so it is with medicine and pain. We see a bunch more pain than the average everyday Joe. We learn to evaluate pain more deeply and we understand more about it. It stands to reason that we would have more words to describe pain.

Most of us are pretty efficient at evaluating pain. We push, we prod, we ask our OPQRST questions and we get an idea about what’s going on. But sometimes we come up short when it comes to describing what we’ve found. When it’s time to hand off to another medical provider we can have those moments when our palette of pain words run dry.

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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.

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