SAMPLE History

The focused history and physical exam answers the question, “why am I here?”

When the EMS crew is confronted with a patient who has a medical problem but there is no mechanism of injury, the medics have to figure out the complaint and formulate a differential diagnosis. A differential diagnosis is a temporary or working diagnosis. The differential diagnosis for EMS is always based on a high index of suspicion (awareness and concern for potentially serious underlying and unseen injuries or illness) of the worst diagnosis that could be causing the patient’s problem. So if a patient is complaining of slurred speech, the working or differential diagnosis should be stroke.

The public calls 911 for a variety of reasons, many of which would not be classified as an emergency (or even a medical) problem. For these calls the focused history and physical exam provides a pattern of behavior that the ambulance crew can employ to determine the patient’s problem. The focused history and physical examination can be performed on scene or enroute to the hospital (whatever makes sense). There are always 3 steps to this assessment; SAMPLE history, vital signs, and a focused physical exam.

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?

So, Why Are We Here Today?

Don’t fall into the trap of assuming that the complaint is as it was when it was dispatched. The public is plagued with a lack of ability to communicate their needs over the phone. In person is where the real complaint can be revealed. The medics should ask open ended questions. An open ended question is a question that can’t be answered with yes or no. The easiest question and most open ended question of all time is, “…So, why am I here?”

Encourage the patient to continue explaining their problem by writing everything down. All Patients love to be listened to. Additionally, gestures such as nodding, or occasionally telling the patient, “I’m listening.” will encourage the patient to continue explaining their problem. This is referred to as facilitation.

Another clue that tells the patient that you are listening to their problem is by repeating the patient’s words in an attempt to gain additional responses. These responses will help the medics clarify any ambiguous statements or words. When the medics are reflecting the patient’s words back to the patient, they should feel free to articulate the feelings expressed by the patient during their ordeal (empathetic response). If the patient’s feelings are completely unfounded, the medics may want to confront the patient (obviously in a respectful manner). The medics may need to interpret the patient’s words into their own words. This is not only helpful in the eyes of the patient (who is convinced the medics are listening to their problems) but can also be useful when the the English language itself is a barrier to communication.

OK, So Why Am I Really Here, Today?

Many times, EMS responds to patient’s with chronic medical problems. Diabetes, seizures, angina, asthma, and psychiatric problems generally can’t be resolved by a singular trip to the emergency department. Before the patient’s problem is resolved (if it gets resolved), there may be many trips to the emergency room via ambulance. So what is the chief complaint when it’s a chronic problem? The chief complaint IS the chronic problem. But instead of asking what is wrong, the medics are asking what is wrong TODAY. When did the problem get so bad that the patient felt like they needed to call 911. Once the medics understand the events that preceded the 911 call, then the reason why the patient requested an ambulance to the scene becomes more obvious. Patients with chronic medical problems call 911 for a variety of reasons, but mostly for the following:

• The hospital discharged the patient after instructing the patient to contact their primary care physician. The problem the is that the primary care physician is either not available for 3 more months or never existed in the first place.
• The hospital discharged the patient with a prescription. The patient, for whatever reason, was unable to obtain the medication and needs to be taken back to the emergency room so they can get some medication.
• The patient has a serious chronic medical or psychiatric condition and also a domestic situation that is unstable and volatile. Had the domestic situation been stable, there would have been no need for EMS in the first place.
• The patient is addicted to narcotics or other medicine and generally calls 911 for transportation to the emergency department to get their fix.
• It’s just hot outside and there is no air conditioning.

Inquiring about the present illness should lead to follow-up questions that seek to find individual factors that could have resulting in the patient’s condition deteriorating. Medications not being filled, tobacco use, alcohol or drug abuse and diet can result in a patient’s condition that is only getting worse. Some patients are just hungry because they have no money for food. Perhaps the patient is a victim of domestic abuse or someone is stealing their medications.

Factors Influencing The Data Collection

At this point it should be established that the reasons the ambulance was summoned to the scene and the real reasons why the ambulance is on scene can be two different things. The patient is more often than not the best provider of information, however family, friends, bystanders, and other public safety personnel can be just as good. Use what the call gives you. Sometimes the call only provides you with medical jewelry to help guide the response. If that’s all that’s there, use it.

Sometimes getting a clear picture of what is wrong with the patient is impossible. In these situations, it may be necessary to ask and document a chronological history of what happened before 911 was called.

Ok, So Where Do You Need To Go?

After obtaining whatever information about the patient is available, it becomes necessary to figure out how to resolve the call. Sometimes, the patient would be best served going to a facility that doesn’t have an emergency room (which probably means the ambulance won’t be able to transport). Figuring out the best place to go is absolutely an EMS task. The reality of 911 is that if the ambulance doesn’t take steps to resolve the patient’s problem, they will just call back (probably on the same shift). Resolving the call is more important than transporting.