English
中文The Patient
This case study is based on an 85-year-old male patient who was attended to following a 999 call from his wife.
History
The history and clinical examination of patients serves as the main source of information for paramedics in emergency practice. (Aldrich, J. 2005) It allows them to effectively assess the patient and thereby determine what if any pre-hospital investigations and subsequent management will be required. The degree of importance placed on history and examination thus requires that it be done skilfully.
In taking the history of this patient, a problem-orientated approach was used to take a focused history concentrating on the main complaint and using the systems review to ensure that no other important aspects were omitted. Another important part of the history, particularly in emergency medicine is the past medical and medication history. These can have implications for the likely cause of the current problem and also on treatment that may be safely given to the patient. It is thus important that this is done as accurately as possible. In assessing this patient, the medication along with dosing information was taken and matched to the medical conditions for which the drugs were being taken. Matching drugs to diseases reduces the likelihood of drugs being omitted and provides additional information for the hospital staff as some drugs may have multiple indications.
Taking a good history can however be quite challenging in the pre-hospital environment. Patient may be too unwell to provide a history and so paramedics will depend on third parties such as witnesses and family members to provide the history.
Pain is a common experience of patients in the pre-hospital setting and in a study to develop national estimates of the epidemiology of pain in the pre-hospital setting, 20% of patients reported moderate to severe pain. (Domeier, RM. 2002) Anxiety relief and pain control are important aspects of pre-hospital care and it is the responsibility of pre-hospital clinicians to promote comfort and reduce pain.
The experience of pain is complex and varies widely. Several pain management tools have thus been developed in an effort to provide valid and reliable methods of quantifying it. Since the experience of pain is subjective, patient self-reports provide the most valid measure of the degree of pain and the most commonly used scoring systems are the visual analogue scale and the numeric self-rating scales. (Katz, J. 1999) Careful assessment of pain is required in the pre-hospital assessment to allow the provision of adequate analgesia and improve outcome. (Hatlestad, D. 2001)
A pain score was used in the patient’s assessment to quantify the pain. The method used was a numeric self-rating scale. This scale goes from one to ten with a score of ten being the most imaginable pain. This patient reported a score of seven, thus rating his pain as moderately severe. Despite the fact that the patient’s pain score was enquired about and recorded, it was not acted upon and no analgesia was provided to the patient.
Examination
Examining patients in the out-of-hospital setting can prove to be quite challenging. Paramedics must therefore choose and concentrate on those examinations that are pertinent to the patient’s immediate care. This is a focussed examination. In the examination of this patient, a focussed neurological assessment was carried out as the presenting complaint was of a neurological nature. It was then supplemented by a rapid general assessment of the patient. Full assessment possibilities of the neurological system include a full cranial nerve examination, examination of the cerebellar system, and, full assessment of the motor and sensory system including proprioception. One would argue that this is too lengthy and detailed for pre-hospital assessment of a patient and may indeed not add very much to the information already gathered whilst being time consuming.
One way of assessing the patient’s neurological status, particularly their conscious level is the Glasgow Coma Scale (GCS). This is a widely used scale that is simple and well established. One advantage is that when started in the out pre-hospital environment, it can be continued in hospital and used to monitor the patient’s progress. Pre-hospital GCS assessment has been shown to be as good a predictor of mortality as more in-depth APACHE II scores measured in hospital (Gašparovic V, 2001).
In a patient who is not speaking, the conscious level may also be assessed using the AVPU system as described below (Jones, K. 2003)
1. A – Alert (GCS 14-15)
2. V – Responds to Vocal stimuli (GCS 9-13)
3. P – Responds to Painful stimuli (GCS 4-8)
4. U – Unconscious (GCS 3)
A “FAST” test for stroke was used in the neurological assessment of this patient. This is a test that is used to help people to quickly recognise the symptoms of stroke. It is an easily remembered mnemonic consisting of the following components.
1. Facial weaknss – can the patient smile? Is there eye or mouth drooping?
2. Arm weakness – can the patient raise both arms?
3. Speech problems – can the person speak clearly and understand wha you say?
4. Test all three symptoms
It is used by paramedics to diagnose stroke prior to the patient being admitted into hospital. The national stroke association has funded further research towards validating this test (www.stroke.org.uk). The patient’s principal complaint was headache and not weakness. It is nevertheless still important to consider the possibility of stroke in a patient with a neurological complaint and thus the “FAST” test was appropriate.
The abbreviated mental test score (AMTS), introduced by Hodkinson in 1972 is one of the tests that were available for use in assessing the patient. It is a ten question mental test score available for rapidly assessing elderly patients for the possibility of dementia. (Hodkinson,H 1972) It is a validated and widely used screening instrument. It is widely used in clinical and research settings for detecting and monitoring cognitive impairment. (Holmes, J. 1996) It is also used to assess confusion. The maximum score of the test is ten and a score below seven indicates cognitive impairment.
The AMTS has the advantage of being easily administered and well tolerated by both subjects and scorers. A Disadvantage of this test however is that there may be inconsistencies in giving and scoring the test and this may affect its reliability and sensitivity in detecting change. Patients will also need to be reasonably knowledgeable to know information like the date of the First World War, one of the questions tested.
It is important that out of hospital staff have a validated and widely used instrument available to assess confusion. This is because confusion is such an abstract concept, but one that has many important implications, including the ability of a patient to provide valid consent for procedures. Documenting the degree of cognitive impairment using a well known scoring system thus allows continuity of care as the test can be applied during the patients hospital visit to check improvements or decline in their cognitive function.
Limitations of the pre-hospital environment
Pre-hospital teams are often faced with the prospect of having to assess patients in difficult situations under time pressure. This limits their ability to accurately assess patients, as they may not always have access to a good patient or event history. In the assessment of this patient, this was not a significant problem as the patient was conscious and able to provide a history.
It was not possible in the assessment of the patient to perform some of the examinations that were deemed necessary such as ophthalmoscopy, otoscopy and examination of the oropharynx. This was due to lack of equipment. This is also a limitation of the pre-hospital environment, as teams do not always have access to the full range of equipment that they may need. There is of-course, a limit to the amount of equipment that may reasonably be carried by pre-hospital teams. One has to wonder whether having access to an ophthalmoscope or an otoscope would have significantly altered the management of this particular patient.
Pre-hospital care providers are frequently exposed to violent environments. In a study to investigate the proportion of pre-hospital personnel who had experienced such behaviour, 61% of staff reported having been assaulted on the job with 37% requiring medical attention and 25% sustaining injury from the assault. (Corbett, SW. 1998) This expectedly limits their ability to effectively assess the patient.
Overall, despite the challenges faced in the pre-hospital environment in the assessment of patient’s, studies show that pre-hospital teams are quite accurate in assessing significant illness and injury (Benner, JP. 2006).
