Patience; It`s More Than a Virtue

     On the typical garden-variety EMS response, once the initial assessment has been completed and any life threats have been addressed, patient assessment typically slows down and focuses primarily upon data acquisition.

     In most medical cases, the patient's chief complaint drives the history-taking process and physical examination. Add the information gleaned from the history, physical, assessment and evaluation of the emergency scene, plus diagnostics—vital signs, blood sugar, cardiac monitor, pulse oximetry, capnography, temperature, etc.—and, for the most part, comprises your fund of knowledge relative to a particular patient and event.

     For most EMSers, once we establish that short-term relationship with a patient and get the information flowing, we hate to lose our momentum and risk breaking up the flow. Unfortunately, with that momentum we often increase the speed with which we ask our questions, moving from one to the next in that pattern of question and answer that, over time, becomes our "style."

     By simply being aware when this increase in the speed of your questioning is happening and by constantly being a bit more patient, you can allow the patient to be in control of the flow of information. I've had many cases where patient-moderated information flow led to a valuable piece(s) of patient history, just as I was about to move on to a different line of questioning. If not for that brief pause, that information would have remained unspoken, at least for the time being, and maybe permanently.

     Let's look at some situations where you may be challenged in your quest to obtain a complete and accurate patient history, and suggestions for how best to mitigate the impact of such challenges on the patient assessment process.

The Patient Doesn't Trust You
     You are a new EMT-B, and while your driver's license says you are 18, you look 15. On your second shift, you encounter an 85-year-old female patient in the midst of some medical crisis. Here you are all shiny and clean and looking fifteen, and you start asking incredibly personal questions from an elderly woman whom you have known for 15 minutes. These are questions that she might not answer for her personal physician, whom she has known for 15 years.

     Given that a significant number of EMS providers are young, this scenario plays out far more frequently than we would like. Like it or not, this mismatch of the very young caring for the very old is a daily reality.

     It is worth keeping in mind that people don't live into their 80s or 90s by being lucky or stupid. Because of their life's experiences, however, folks in this age group are often a bit cynical, if not downright hesitant, to put much faith into what looks to be a 90-day wonder, i.e. "He looks like he's been out of school for 90 days…I wonder if he has a clue about what he's doing." If you present yourself as a polite, caring, competent professional, and show that you can be trusted, that the barrier of youth can be overcome. But don't think you'll pull this transformation off in the first few minutes of a call. When trust is the issue, you may find that your assessment efforts almost grind to a halt until you win the patient over, and that takes time, patience, and proving you are worthy of having their private information and being entrusted with their care.

The Patient Is Having Trouble Recalling the Answer
     Sometimes, a patient actually knows the answer to your questions, but is having trouble retrieving that particular mental file. Under these circumstances, you should immediately think oxygen or sugar—the two things that a human brain must have to function, although it can store neither of them. A quick fix for hypoxia or hypoglycemia can bring a brain back up to speed in no time and get you back in the information-gathering game. However, when the patient's mentation has decreased and the cause cannot be readily identified or corrected, having extra patience may again yield the dividends you are hoping for. In those cases where the patient's brain is working at sub-par levels, if you remain patient, periodically coaxing or using other "active listening techniques" often allows you to slowly extract the required information. Decreased mentation, in and of itself, is not a good reason to abandon assessment efforts.

The Patient Doesn't Know the Answer
     In some cases, the patient may simply not know the answer to your query. In that case, no amount of patience will improve your information-harvest. Under these circumstances, you face a different challenge. At some point, you must decide when you have waited long enough, then move on to other questions that are more likely to yield the information you need to make patient-care decisions.

Conclusion
     The timely acquisition of a patient's history is one of the cornerstones of quality prehospital care. When it's all said and done, I hope you agree that patience is much more than a virtue when you are doing patient assessment. It's a necessity if you wish to optimize the amount and quality of the information you receive in order to provide the best patient care. Until next month…

Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of EMS Magazine's editorial advisory board.

EMS EXPO™
Mike Smith is a featured speaker at EMS EXPO, October 15–17, in Las Vegas, NV. For more information, visit www.emsexpo2008.com.