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CBT/OTEP 165: SICK/NOT SICK

CBT/OTEP 165: SICK/NOT SICK. Introduction. The EMS provider’s chief aim is to decide who is critically ill and who is not. SICK/NOT SICK is a method of rapid patient assessment that helps you make good decisions based on proven clinical indicators. Terms.

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CBT/OTEP 165: SICK/NOT SICK

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  1. CBT/OTEP 165:SICK/NOT SICK

  2. Introduction • The EMS provider’s chief aim is to decide who is critically ill and who is not. SICK/NOT SICK is a method of rapid patient assessment that helps you make good decisions based on proven clinical indicators.

  3. Terms • index of suspicion —The anticipation that certain types of accidents will result in certain types of injuries. • mechanism of injury — The forces of injury and how they were applied to the body. • nature of illness — Circumstances or findings that suggest a possible disease.

  4. Terms, continued • perfusion — The flow of blood through the organs and tissues of the body. • RPM — An acronym that stands for respirations, pulse and mentation. • skin signs — Observable indicators of circulatory status that include skin color, temperature and moisture.

  5. New Terms • SICK — Someone who appears physiologically unstable as indicated by clinical indicators. Other terms that mean SICK include critical, urgent or unstable.

  6. New Terms , continued • NOT SICK — Someone who appears physiologically stable as indicated by adequate respirations, pulse, mental status, skin signs and an appropriate body position. Other terms that mean NOT SICK include non-critical, non-urgent or stable.

  7. Resources • The recertification exam for this module is based on a variety of resources. We recommend that you review the following: • Chapter 8 – Initial Assessment in Emergency Care and Transportation of the Sick and Injured, 9th edition (AAOS).

  8. Purpose of SICK/NOT SICK • Help you accurately determine who is critically ill and who is not • Assure a rapid initial assessment • Prevent delays in patient care SICK or NOT SICK

  9. Concept of SICK/NOT SICK • Has been around for years • Integrates with any rapid initial assessment program • Facilitates coordination and communication in the field • Results in better patient care SICK or NOT SICK

  10. What is a SICK Patient? • A SICK patient is one who appears physiologically unstable as indicated by key clinical signs. • This patient has what you think may be a life-threatening injury or illness and needs immediate BLS care and advanced life support (ALS). • The SICK patient can die quickly unless you initiate aggressive BLS and ALS treatment and rapid transport.

  11. Identifying a SICK Patient • You can identify a SICK patient by looking at six clinical indicators: • Respirations • Pulse • Mental status • Skin signs • Body position • Evidence of significant mechanism of injury

  12. Identifying a SICK Patient, cont'd • It may take only one indicator to decide that a patient is SICK: • Significant mechanism of injury • Respiratory distress • Weak or no radial pulse • Altered mental status • Poor skin signs • Inappropriate body position

  13. Then What is NOT SICK? • A NOT SICK patient is someone who appears physiologically stable as indicated by clinical indicators. • NOT SICK does not mean "not ill" or "not injured." • It means the condition is not life threatening at the moment.

  14. Then What is NOT SICK?, cont'd • The NOT SICK category does not mean there is nothing wrong with a patient. • It means that you see no life-threatening conditions at the current time. You can reclassify the patient as SICK and move to a more aggressive response at any time during the course of caring for the NOT SICK patient.

  15. How It Works (While En Route) • Discuss three possible scenarios based on the dispatch information. • Formulate a plan based on scenarios. • Make a decision early in the call. • Take action.

  16. For Example • You are dispatched to a 35-year-old female with syncope. You can begin this call by discussing with your partner questions such as: • What can cause syncope? • What is the patient’s environment? • What equipment might we need? • What is our plan on arrival?

  17. The Clinical Picture • An impression or mental image you form from observing a patient • NOT a diagnosis! • Answers the question: "Is the patient likely to survive without immediate and aggressive action?"

  18. The Clinical Picture, cont'd • The clinical picture for a medical patient has these basic elements: • Chief complaint/Nature of Illness • Respirations • Pulse • Mental status • Skin signs • Body position

  19. The Clinical Picture, cont'd • The clinical picture for a trauma patient has these basic elements: • Chief complaint/Mechanism of Injury • Respirations • Pulse • Mental status • Skin signs • Obvious trauma

  20. Chief Complaint • The chief complaint can help focus on which body systems or areas are affected. • What is the chief complaint? • What made you decide to call now? • How is this different than before? • What immediate treatment is required?

  21. Nature of Illness (NOI) • Any information that hints at a probable cause for a chief complaint in a medical patient. • Any circumstances or findings that suggest a possible disease. A history of fever lasting two days followed by a stiff neck may suggest meningitis. Weakness in an elderly woman that may suggests a myocardial infarction.

  22. Mechanism of Injury (MOI) • May indicate underlying injuries • Consider all relevant factors such as: • Type and size of vehicle • Damage sustained by the vehicle • Type of weapon • Height of the fall

  23. Respirations • Rate: normal, fast or slow • Character: normal, labored, or shallow A patient with shallow respirations, labored breathing, or dyspnea is SICK.

  24. Pulse • Presence of a pulse and pulse character are good indicators of cardiovascular function. • Check the pulse by palpating the radial pulse in a conscious patient. • Check the carotid pulse in an unconscious patient.

  25. Mental Status • Abnormal behavior can be a sign of underlying injury and poor cerebral perfusion caused by hypovolemia, hypoxia or cardiac dysrhythmias. • There are many subtle signs that signify changes in mental status; for example, anxiety, lethargy or drowsiness. You may need to ask about prior medical history to determine what is normal for this patient.

  26. Skin Signs • Skin color gives you clues about circulatory and respiratory function. The three skin signs are: • color • temperature • moisture Poor color = poor circulation and/or oxygenation = SICK

  27. Body Position • A reliable indicator of respiratory effort, level of consciousness, and ability to compensate for shock. • Important information about the overall status of the respiratory, circulatory, and neurologic systems in a medical patient.

  28. Obvious Trauma • Obvious trauma can significantly impact the clinical picture and suggests classification in the SICK category. • Strongly consider a SICK decision when faced with multi-systems trauma, head trauma, bilateral femur fractures or chest injuries.

  29. 1— Form a clinical picture.

  30. 1—2 Form a clinical picture. SICK or NOT SICK Make a decision

  31. 1—2—3 Form a clinical picture. SICK or NOT SICK Make a decision Take action—go to work.

  32. FAQ • The SICK path puts the EMS team into an action mode: ALS and rapid transport. • The NOT SICK decision leads down the path of a thorough, on-the-scene exam and appropriate treatment. What if the patient changes? *You can switch from NOT SICK to the SICK course of treatment if the patient’s status worsens or you discover new information.

  33. FAQ • SICK/NOT SICK allows you to make a decision based on the information you have at the moment. • You can’t go wrong by treating a patient based on what you see clinically. • It is okay to start BLS level treatment without knowing for sure what is going on. What if I make the wrong choice?

  34. FAQ What mistakes do people make? • Failing to respond to new information • Tunnel vision • Poor planning

  35. Summary • SICK/NOT SICK helps you decide who is critically ill and this speeds delivery of care. • Formulate three scenarios while en route.

  36. Summary, continued • The five elements of a clinical picture include: • Chief complaint • Respirations • Pulse • Mental status • Skin signs Nature of illness, body position, mechanism of injury and obvious trauma also play a role in forming the clinical picture.

  37. Summary, continued • The SICK patient appears physiologically unstable as indicated by inadequacies in: • respirations • pulse • mental status • skin signs • body position • evidence of significant mechanism of injury

  38. Summary, continued • The NOT SICK patient appears physiologically stable as indicated by adequate: • respirations • pulse • mental status • skin signs • body position • evidence of significant mechanism of injury

  39. Summary, continued • If the clinical picture is unclear, select NOT SICK, begin necessary treatment and continue with assessment. • NOT SICK does not mean that the patient is not injured or ill…it means that the patient appears stable at this time!

  40. Questions EMS OnlineGuidelines and Standing Orders http://www.emsonline.net/downloads.asp Mike Helbock, M.I.C.P., NREMT-PTraining Division Manager Email support:help@emsonline.net Dr. Mickey EisenbergMedical Director Ask the Doc: http://www.emsonline.net/doc.asp

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