Collect The Right Information

The best source of information about the patient is the patient. The patient knows what hurts and how bad. Just ask. In lieu of the patient, ask the family. Rarely does EMS experience patients who are completely alone. EMS is responsible for collecting the following information on all patients encountered:

• Correct dates of conditions and last visits to hospitals
• Correctly record the times of the call (given through dispatch)
• The patient’s age
• The patient’s sex
• The patient’s race
• Previous medical history
• Previous trauma or surgical history

Components Of A Patient History

The interview is always the same and follows a set pattern of questions. Questions that occur to the ambulance crew after this conversation would be referred to as a follow up question.

• Subjective – This is the patient’s chief complaint as defined in terms of onset, provocation, quality, radiation, severity, and time. The patient says they have chest pain, then the medics ask about OPQRST (onset, provocation, quality, radiation, severity, and time).
• Allergies – The patient is probably allergic to a medication. Having a drug allergy means that when the patient takes the medication they have an allergic reaction. Many patients will confuse a medications side effect with an allergy. Not a problem for the ambulance crew. Simply write down the allergy and what happens when they take the medication.
• Medications – Patients are prescribed numerous medications. The EMS crew should write down each medication, the dosage for each mediation, and how many times they take the medication per day. Having a good list of medications is important to the rest of the health care team.
• Previous medical history – Inquire about the patient’s medical history. What medical conditions are they being treated for? What surgeries have they had? Is the patient undergoing some sort of holistic health treatment such as exercising, special diet, or fasting?
• Last meal or oral intake – What was the last thing the patient ate. It doesn’t make that big of a deal most of the time, but if the patient needs surgery, the anesthesiologists are definitely going to want to know.
• Events preceding the complaint – What was the patient doing before they started experiencing the pain that led them to call 911?

Any question formulated after having this conversation would be referred to as a follow up question. Examples of follow up questions could be:

• Do you have any plans to kill yourself?
• Did you go back to the same doctor after the incident?
• Have you ever eaten octopus before?

History Of The Present Illness

When the patient presents with a chronic complaint (as is often the case), it is useful to figure out what is different or worse today than usual. People everywhere are suffering, but for the most part they would rather suffer at home than in a crowded emergency room.

• “Where is hurting today?” .
• “When did it start getting bad enough for you to call 911?”
• “What makes the pain better?”
• “What position is more comfortable?”
• “Can you describe the pain?”
• “Does the pain move anywhere?”

In addition to asking the usual questions, it may be helpful to inquire about the nature of medical treatment (and locations). Patients with chronic medical conditions are typically served by multiple physicians (none of who know the other exists). Travel and social history may somehow play into the patient’s condition.

Medics often overlook the importance of asking enough questions to actually try to figure out what is wrong with the patient in favor of transporting the patient to the emergency department. The emergency department is often far too busy to pick up on the subtle nuances of the patient’s problem and will quickly discharge the patient home. The cycle continues after the patient returns home, having traveled all over town in search of a solution. All the patient needed was somebody to listen to their problems and try to solve them. Could this be you?