The Patient Assessment

[Eydawn]

BLS providers, by and large, are NOT taught critical thinking skills. Nor are they taught much of anything else for that matter.

I think the difference is that you may do the same actions within an assessment, or many of the same actions, but if you can't interpret what you're taking in, it doesn't make a damn bit of difference. The assessments are different by virtue of being able to interpret information differently. I don't view the physical skills of assessment as "the assessment" nor do I view history taking the same way as I did as a brand new uneducated Basic. My assessments are VASTLY different now than they were previously, so I stand by what I said in my previous post. They are different assessments.

Wendy

CO EMT-B

[armymedic571]

I think it depends on what do you consider sick/not sick to be... if sick/not sick means unstable/stable as in recognizing a near arrest patient in respiratory distress thatt needs immediate ALS care, or any other immediately life treating condition then yes, I think a BLS provider can and should be thaugh what to look for; however usually it takes only a visual primary survey to recognize such critically unstable patients so that the assesment a basic need to do is really well... basic! For example there's no need to palpate an abdomen or auscultate lung sounds to make a decision between critical and not critical.

If, on the other side, by sick/not sick you mean be able to recognize, based on your physical evaluation and history, that a patient, while stable, is suffering from a condition that might make him deteriorate within a short time (for example recognizing the presentation of a possible polmunary embolism in an otherwise healthy young patient with dyspnea and chest pain) then no, I think most basics will not have a clue... they might tell you what they're seeing if you ask them, but usually don't appreciate the significance of the signs they arere reporting, nor their relative importance.

So, if I understand you correctly. You are saying that although a BLS provider could go though the steps, that they might not appreciate the subtle clues that are present, as a more educated, more expeienced provider would?

I really think that you can't gloss over the above.

I realize you're trying to emphasize the education gap, as par for the course around here, but the fact remains that a Basic provider could literally be a FACEP in his day job, and a medic could actually be the world's biggest idiot; the first is NOT going to be able to truly assess to the level you're looking for, and the second may very well be able to, even if he's too dense to put it all together.

I CANNOT feel a pulse and tell you a patient's underlying cardiac rhythm or abnormalities. It is literally impossible. I can GUESS, depending on regularity, rate, and strength, and correlating with history and other presentation, but even if it's seemingly a gimme (A-fib, say), it will still only be a GUESS. The medic who runs an ECG can, if he is not brain-damaged, tell me what rhythm the patient is in. The fundamental difference between us is that he can use that tool and I cannot.

So I grant that the underlying assessment follows the same path, and is looking for the same things; but there is a certain level of clarity that is simply unavailable without the appropriate diagnostic tools, and in some cases that level is the critical one for recognizing conditions or narrowing a differential from meaninglessly large ("sick") to useful.

How exactly am I glossing this over? Seems some here are coping out over the inability to do a patient assessment. (Not you specifically. Please don't be offended)

I don't like your analogy. I am talking about the physical assessment. I think you are putting too much emphasis on the diagnostics. Besides, if the Medic was as stupid as you say, he/she wouldn't know what to do with those either.

I also don't like the pulse comment. All providers are taught to check a pulse. Is it present? Stong, or weak and thready? Regular or irregular? At that point who cares what the rhythm is, we are trying to determine adequacy in perfusion.

Thanks for the feed back. I really do appreciate it.

I voted that assessments are different with 'skill level'. It is really quite simple.

Education is honestly the difference between the assessments. Generally speaking, the more educated and/or more specialized the provider, the more detailed and conclusive an assessment should be. The more you know about how the human body works, the more you can suspect and assess for illnesses. Sure, the actual act of hands being placed on a patient may be similar between license levels, but the depth of the assessment will not be the same. How many Basics do you see perform assessments of the heart tones and cranial nerve exams? How many paramedics do you see perform assessments of tendon reflexes? The list can continue right on up the ladder. What is next, are we going to say that paramedics and nurses perform the same assessments?

Someone said it in another post, but it applies. How can you assess for something if you have no idea it even exists? The quality of the assessment is dependent on the depth of education.

Matty

Matty,

Thanks for the honset reply. And of course Paramedics and Nurses don't perform the same assessment (Nurses would have to go back to school)

Just kidding .....

BLS providers, by and large, are NOT taught critical thinking skills. Nor are they taught much of anything else for that matter.

I think the difference is that you may do the same actions within an assessment, or many of the same actions, but if you can't interpret what you're taking in, it doesn't make a damn bit of difference. The assessments are different by virtue of being able to interpret information differently. I don't view the physical skills of assessment as "the assessment" nor do I view history taking the same way as I did as a brand new uneducated Basic. My assessments are VASTLY different now than they were previously, so I stand by what I said in my previous post. They are different assessments.

Wendy

CO EMT-B

Your first sentence is a little harsh don't you think? If your basic providers are that bad. Then...

Your second statement is more towards what I was getting at. But, what has changed in your assessment? The steps, or the way you interpret the information you find?

Thanks again... .

[Kiwiology]

BLS providers, by and large, are NOT taught critical thinking skills. Nor are they taught much of anything else for that matter.

I think the difference is that you may do the same actions within an assessment, or many of the same actions, but if you can't interpret what you're taking in, it doesn't make a damn bit of difference. The assessments are different by virtue of being able to interpret information differently. I don't view the physical skills of assessment as "the assessment" nor do I view history taking the same way as I did as a brand new uneducated Basic. My assessments are VASTLY different now than they were previously, so I stand by what I said in my previous post. They are different assessments.

Wendy

CO EMT-B

You make a very good point there Wendy; the actual physical skills of assessing your patient do not change at any pracric level you are still going to take vital signs, look at perfusion status and respiratory effort etc. What changes will be what you do with that information and how you use it to change what you are going to do with your patient.

For example the very first call I went on that required some critical thinking was a guy who called up at 1am because his GTN (NTG) wasn't working on his chest pain. I had no real idea what I was doing and the Intensive Care Paramedic did all the work; I don't actually remember doing much of anything. I sort of stumbled my way through with a vague idea of what was going down and had no real clue what on earth the information gathered meant eg blood pressure, ECG, perfusion status assessment. Basically ask the questions the way the book tells you and hope they are right.

Another call came down the pipe to us one evening to go and pick up a guy from urgi-care. Get on scene and it's an older gent is having chest pain; first thing the nurse does is hand me a 12 lead ECG; take a look and it doesn't look so hot with big ST changes in the anterioseptal leads (V1,2 and 3). The patient complained of being short of breath and nauesous; he looked sweaty and a little unwell.

Now this second call went a million times better because I'd gone and hit the books and taken some nursing classes; I knew wgat was wrong with him, why he had the symptoms he did, how they were affecting his body, what we could do about them and what he needed. I knew to ask more focused questions and what might happen to this guy in the very near future while I have him in the back; e.g. he might crash. I didn't stand there with my thumb up my ass doing nothing without a clue what to do.

This is why I advocate strongly that you need a good grounding in biomedical science before you set foot out the door as an ambo; doesn't matter if you are working the transfer nana van or going to emergencies.

[Brandon Oto]

How exactly am I glossing this over? Seems some here are coping out over the inability to do a patient assessment. (Not you specifically. Please don't be offended)

I don't like your analogy. I am talking about the physical assessment. I think you are putting too much emphasis on the diagnostics. Besides, if the Medic was as stupid as you say, he/she wouldn't know what to do with those either.

Maybe I misunderstood your question. If you're specifically referring to the physical assessment only (or physical + hx), then that's a separate story and I may not especially disagree. To me, "assessment" means the entire scope of information-gathering tools available to the provider, from his eyeballs to the machines with dials and lights. There's no particular difference between palpation and blood glucometry, except that some people can get in trouble for doing one of them. All just info and all part of the assessment.

And as you say, anyone can either take the information gathered and use it meaningfully, or be without a clue as to its significance. But again, to me, that's not part of assessment; that's part of diagnosis and treatment. I should be able to "assess" a patient and hand you a paper with everything I learned on it; you could then use that data to diagnose and treat, and we've done separate jobs.

Obviously the two parts usually go hand-in-hand and should interact. But nevertheless.

But maybe this is a digression.

I also don't like the pulse comment. All providers are taught to check a pulse. Is it present? Stong, or weak and thready? Regular or irregular? At that point who cares what the rhythm is, we are trying to determine adequacy in perfusion.

Sure. But the significance of the pulse is largely as a way of viewing cardiac activity (the rest of it is probably as a measure of vessel compliance and distal circulation at that extremity, and an indirect look at BP). The medic and the Basic can both take a pulse, and both probably should; but the Basic can't do anything more (except perhaps auscultate for a rhythm, which is of marginal utility to him). The heart's electrical rhythm is a piece of information he will forever lack, no matter how "good" he is at assessment. Likewise, rhythm is something the medic can and will obtain, whether or not he's able to parse its significance.

Like I said, getting the information and using it are different skills. Getting it as part of the assessment. Using it (whether to treat, or to inform transport decisions, or to form a working diagnosis, or anything else) is something more and something separate.

[armymedic571]

Maybe I misunderstood your question. If you're specifically referring to the physical assessment only (or physical + hx), then that's a separate story and I may not especially disagree. To me, "assessment" means the entire scope of information-gathering tools available to the provider, from his eyeballs to the machines with dials and lights. There's no particular difference between palpation and blood glucometry, except that some people can get in trouble for doing one of them. All just info and all part of the assessment.

And as you say, anyone can either take the information gathered and use it meaningfully, or be without a clue as to its significance. But again, to me, that's not part of assessment; that's part of diagnosis and treatment. I should be able to "assess" a patient and hand you a paper with everything I learned on it; you could then use that data to diagnose and treat, and we've done separate jobs.

Obviously the two parts usually go hand-in-hand and should interact. But nevertheless.

But maybe this is a digression.

Sure. But the significance of the pulse is largely as a way of viewing cardiac activity (the rest of it is probably as a measure of vessel compliance and distal circulation at that extremity, and an indirect look at BP). The medic and the Basic can both take a pulse, and both probably should; but the Basic can't do anything more (except perhaps auscultate for a rhythm, which is of marginal utility to him). The heart's electrical rhythm is a piece of information he will forever lack, no matter how "good" he is at assessment. Likewise, rhythm is something the medic can and will obtain, whether or not he's able to parse its significance.

Like I said, getting the information and using it are different skills. Getting it as part of the assessment. Using it (whether to treat, or to inform transport decisions, or to form a working diagnosis, or anything else) is something more and something separate.

Agreed. Fair enough then.

[Eydawn]

You're basically arguing as to whether you define an assessment by the tools used in that assessment or by the use of information gleaned from use of those tools. I argue that it is the use of information and the knowledge of which tools to use that makes the ALS assessment different.

Wendy

CO EMT-B

[Kiwiology]

You're basically arguing as to whether you define an assessment by the tools used in that assessment or by the use of information gleaned from use of those tools. I argue that it is the use of information and the knowledge of which tools to use that makes the ALS assessment different.

Wendy

CO EMT-B

I agree Wnedy, it is the knowledge that makes it different. For example one ambo I know wrote up he checked the blood sugar of a cardiac patient because they were nauseous and sweaty which are signs of being hypoglycaemic. When quizzed he could offer no further information as to WHY he did it, never mind this patient had no diabetic history and that being sweaty and nauseated were 1000x more likely to come from the cardiac problem than an acute hypo!

A few lower level providers ("BLS") have said an asthma patient who it not wheezing is a good sign, well, it might be, but it never occurs to then that they might not be moving enough air to make a wheeze.

Not only is assesment different but I find treatment is also different; there was one ambo here who put another cardiac patient on six litres of oxygen because "the heart muscle is not getting enogh oxygen". When asked if the amount of oxygen inspired was the amount that reached the tissues once again cue the glazed over look and the shurgged shoulders. We know oxygenation and ventilation are very different processes.

Again .... bravo to Ontario for providing it's Primary Care Paramedics with two years of solid education so they can begin to build good, solid clinical pictures in thier head when they hit the street.

[armymedic571]

You're basically arguing as to whether you define an assessment by the tools used in that assessment or by the use of information gleaned from use of those tools. I argue that it is the use of information and the knowledge of which tools to use that makes the ALS assessment different.

Wendy

CO EMT-B

NO, NO, NO....

I am trying to say that the tools are just that. TOOLS. It is the art of the assessment, the physical hands on of the patient and interview that are the important points.

It is a fact, step by step, the patient assessments are the same. MY POINT and the bottom line, is that education does make the difference. (Funny how we seem to be arguing the same point! )

I have attached two skill sheets from NR. One BLS and the other ALS. They are (except for diagnostics) the same.

Patient%20Assesment.pdf

patientassessmentmanagementmedical.pdf

[Kiwiology]

I have attached two skill sheets from NR. One BLS and the other ALS. They are (except for diagnostics) the same.

Those skills sheets look a bit dodge mate. Now I know you did not design them but honestly, WTF

- They are written in 2000, like nothing has changed in a decade?

- Why are BLS providers failed if they do not provide oxygen? See my many postings on that there is nothing magic about oxygen!

- ECG for every shortness of breath .... maybe but not thinking so

- Scarily, a GCS is not part of patient assessment in your land?

- Ruling out trauma, well, shouldn't that be done at the scene size up; hard to make a decision about c-spine without it

I can't find one of ours to compare it too but I'm looking

[Eydawn]

You keep asking me the same damn question, just phrased differently, so I figured that must have been the angle you were going for otherwise you would have understood my posts and said "yes, that's what I was getting at, education makes the difference." I don't know how many times I said that only to have you ask AGAIN what I was getting at.

Usually people comment on the clarity of my writing... wtf happened here?

Just because I didn't phrase it the way you wanted me to phrase it you kept on it. I stand by all the posts I have made. The assessment ITSELF is different by virtue of the brain performing the assessment being programmed differently.

(Sorry if I sound cranky, I had a rather rough shift and am studying for a microbiology exam at present...)

Wendy

CO EMT-B