I talk to Dr Sarah White, an anaesthetic registrar at Chester about assessing an unwell patient. We deliberately chose to use an example case of a breathless asthmatic patient simply because extremely short of breath patients are unforgivably scary for doctors of any stage in training, even experienced consultants. At a later date, we will discuss asthma but for now, take on board the advice you need to enhance your practice with the unwell.
Find the podcast at the end and a link to iTunes.
The case for the discussion is a 35 year old lady, admitted with asthma. As the ward cover doctor, you are bleeped by the nurse to come and see her. Her observations are: RR >40, SpO2 88%, HR 156, BP 90/60, unable to speak in sentences but alert.
What are your first thoughts about this case? How would you feel if you received that information over the phone?
It would be natural to feel uneasy, even scared at the prospect of such a patient. Be assured, you already have all the tools you need to deal with the situation. The nurse that contacted you is after a response and how you respond can set the tone for the whole encounter. You have options available to you. You can just tell them you’re coming and leave the conversation there. Or you can give instructions of things to happen while you are on your way. Simple instructions to tackle the issues you are presented with can make a difference in the quickest timeframe. For this patient, we would ask for at least oxygen and nebulisers. In a different patient you may ask for simple investigations such as an ECG, blood glucose or if you’re lucky a blood gas. You can often start basic management on a verbal request; a cannula and bloods, IV fluids, oxygen, nebulisers, analgesia, antibiotics. Ask for things to be prepared for your arrival including any of the above or more complex equipment. You may find you have more information to inform you on arrival or that the patient has begun to improve. Instigation and early management is always better and can empower the nursing staff as well. The temptation in the age of e-prescribing may be to just write something and move on, but you do need to see the patient. Don’t be afraid to admit if you think this sounds like it’s above you as you can ask the staff to contact someone else whilst you’re getting there. Often in these situations two sets of hands, eyes and brains are better than one.
The hospital corridor can seem like a long way when you’re heading to an unwell patient. Your mind will likely be racing and you want to keep control of your thoughts. Running to these patients will firstly tire you out but secondly mean you are breathless and potentially more anxious by the time you get there and, when you arrive, you need to be functioning.
Walk briskly. Organise your mind as you go. There are many different resources you can use on the go. You can get hold of most of the Oxford Medical Handbooks on your smart phone, NICE have an app for their guidelines, hospitals often have local guidelines available on a smartphone and there are many other reference medical apps you can use. We don’t endorse any particular one but find one that you like and can access quickly. The benefit of this is that you can read the important points as you go so your plan is firm in your mind for when you get there. There has been a lot of work into checklists and the aid these provide (1) and though we do not suggest ‘checklist medicine’, having a structure to follow when under stress is a one method to improve your diagnostic ability (2). By having a resource that allows a degree of offload, your focus is on assessing the patient and your immediate actions.
Sarah brings up the important factor of who else is around you. You will have seniors you can contact. Just as the person requesting your assistance can contact them, you can too while you’re en route or before arriving. If you think this could be above what you can handle then please contact them. Your senior may not be immediately available and you will have to start things before they arrive but you can do the basics to make sure the patient is safe and treatment has started.
Once you reach the ward, just take a deep breath to really get yourself calm before entering. When I was a competitive swimmer, we used to use meditation and visualisation as a tool to allow us to enter the ‘zone’ quickly and I have translated principles into medical practice. I don’t sit at home meditating but I understand how the process allows me to remain outwardly calm and for the most part it is by controlling my breathing with slow deep breaths and focus. Scott Weingart of EMCrit has spoken at length about some of these principles and it is worth exploring these various resources out if you’re interested (3). Avoid being cognitively overloaded by doing one thing at once and avoid the temptation to multitask. In these situations attempting to multitask is more likely to become trying to do too many things at once.
You enter the ward and are greeted by someone directing you to the bay. Upon seeing the patient what things make you immediately think the patient is unwell? These aspects may well be encompassed by clinical experience and expertise. Indeed, the physical appearance of a ‘sick’ patient is difficult to describe and is certainly not an evidence based description either. As we discuss, a drowsy, non-communicative patient is of concern. The implication of this appearance is that there is either: 1) inadequate cerebral perfusion 2) underlying pathological process disrupting cerebral function. Both of these are serious and life threatening and you need to find and treat them.
ALS, APLS, ATLS, ALERT and almost any teaching about acutely unwell patients uses the ABCDE approach towards the assessment of these patients. What Sarah describes is a real world approach towards efficiently undertaking this.
The most simple and efficient way to begin is ask the patient how they are. An adequate response implies: an open airway, enough respiratory function to talk, adequate cerebral perfusion. It gives you a fast clue that the patient either is or is not ok.
If they are awake, alert and talking without difficulty, the airway is likely patent. However, to assess it look inside for any foreign bodies, swellings, vomit, secretions, blood. If there is something you need to remove and can see under direct vision, remove it. Look at the neck for any masses or swellings and tracheal tug. Listen for any stridor (once heard never forgotten), hoarse voice or gurgling sounds. Feel any swellings and the position of the trachea (I know this is usually breathing but a mass high up may displace it too).
If you have any airway concerns you must get help immediately but do not leave the patient. Provide oxygen and support the airway with simple manoeuvres such as head tilt/chin lift and jaw thrust. If necessary place a simple airway such as a guedel or nasopharyngeal.
This is more that just the oxygen saturations. Look at the effort of breathing, the depth and pattern. By the time you arrive, the resp rate should have been calculated and recent SpO2 taken. Feel the expansion, especially in a breathless patient. Listen front and back carefully. An extremely short of breath patient will be scared and these patients are scary to assess as well. Reassure them you are here to help. Request a chest X-ray if needed and if someone is able to take an ABG (if needed) while you continue your assessment then ask for it but do offer local anaesthetic if you have time. If not done already, feel the trachea’s position. A tension pneumothorax is a clinical diagnosis and needs immediate treatment with needle decompression. Remember, escalating oxygen requirements are concerning and ‘normal’ saturations on high flow oxygen means you have little left at your disposal should they drop any further. Can you treat anything here? Will further oxygen, nebulisers or chest physio help?
When you hold the hand of the patient or touch their peripheries, notice whether they are hot or cold. Cold implies being peripherally shut down, warmth may be good peripheral circulation or it may be a septic or vasodilated patient. Feel the nature of the radial pulse. This is something I do whilst asking my first question just as an automatic action. A rapid, thready or even absent pulse needs attention to the underlying problem. If there is any doubt as to the strength, feel a central pulse as well. If a central pulse is weak, the patient is in trouble. Ask for a blood pressure and heart rate. What IV access does the patient have? Do they need larger or more? Unwell patients needing resuscitation almost always need more than one and need large-bore cannulas. The patient would rather have a slightly larger ‘sharp scratch’ than suffer a poor outcome. This is another job you can delegate to allow you to continue assessing the patient. If you are cannulating, ask whoever is with you to get IV fluids or medication needed ready for when the cannula is in. Take blood now and if you are not getting an arterial blood gas, take a venous in order to get more information sooner. If they need fluid, give it quickly and assess the response.
If you have given enough fluids or the patient is overloaded and you are unable to give any more and are still hypotensive, get help.
Talk to the patient as you assess them and you will get to know their conscious level. Otherwise either use the AVPU or GCS systems. In an emergency, AVPU is much easier to use. You can go back and calculate an accurate GCS later. Someone responsive only to pain (AV P U) has a GCS of 8/15 and has potential for airway compromise. If you want to assess for confusion, asking the AMT4: Age, date of birth, current place and year in an elderly patient is comparable to the full 10 point AMT tool (4). Not to mention easier to remember and faster. If they will obey commands then check localising signs, both arms, legs and face for gross movements. A cerebral injury significant enough to affect conscious level will have gross physical signs. Check pupils for size, direct and consensual response. Small pupils may be morphine, hypoxic brain injury or pontine damage, large dilated pupils may be other poisons or cerebral insults.Has there been a seizure?
Never forget a glucose. The nurses can do this whilst you assess or it should be on your blood gas.
Both high and low body temperatures are of concern and may reflect the underlying issue. Check for bruising, rashes or any other skin changes. Feel the abdomen.
Investigations and Treatments
Anything not already performed that you need get ordered now. Start with those that can be done at the bedside and work outwards from there. Chest X-rays can be performed at the bedside. Treatments should be thought of the same way. Try and request things that will make a difference most immediately.
I would consider a senior or specialist opinion as both investigation and treatment. It is wise to discuss unwell patients you have concerns about with a senior regardless of whether or not they have improved as there may be extra your senior can provide on top of the excellent work you have already performed. It is always worthwhile highlighting these patients in case they deteriorate further after you’ve left or in case they need handing over for review later from your colleagues.
Before you leave, reassess the patient and satisfy yourself you have nothing more to do. Give the staff clear instructions of parameters you are aiming for with regards to observations and signs.
Real World Application
As we talk about in the episode, the real world application of the A-E approach is much more fluid. When I see unwell patients, unless it is immediately obvious an action is needed straight away, I say hello, introduce myself and ask how they are. As they tell me, I take their hand, feeling its warmth and the radial pulse. Once they have finished speaking, check the airway if needed, feel and auscultate the chest and perform a capillary refill then look at observations. Within 30 seconds A-C can be completed. I ask the patient to move their arms and legs with resistance and if they can feel general sensation and is it equal then check pupil response. Following this, I check the abdomen and if needed bony areas. If during this, an area appears of concern, I will spend more time and focus on that area. It takes practice to do this without missing things and it is not a corner cutting exercise. You will find a way of doing it that works for you but a good ABCDE assessment can provide a large amount of information in a short space of time.
Our case resolves with the patient improving, stabilising and being discharged a few days later. However, a patient becoming more unwell despite your best efforts does happen and it is not your fault. In reality, no one is to blame and so long as you did your up most for the patient you can be proud of yourself.
If you want a good resource that is easy to read and delves into more depth, invest in The Essentials of Acute Care. It is a short and simple book but does provide good advice and did influence how I dealt with these unwell patients.
Listen to the episode here:
- Sibbald, M et al, Checklists improve experts’ diagnostic decisions. Medical Education, 2013: 47; 301–308
- Thammasitboon, Satid et al. Diagnostic Decision-Making and Strategies to Improve Diagnosis. Current Problems in Pediatric and Adolescent Health Care 2013: 43(9); 232 – 241
- https://emcrit.org/blogpost/ehpr-part-5-using-mental-practice-visualization-exercises-mike-lauria/ Accessed 11/3/17 15:08
- Schofield I et al, Screening for cognitive impairment in older people attending accident and emergency using the 4-item Abbreviated Mental Test, Eur J Emerg Med. 2010 Dec;17(6):340-2
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NB. I have received no incentive to recommend The Essentials of Acute Care, I genuinely just think it is worthwhile