1. Copyright 2007 Seattle/King County EMS CBT/OTEP 165: SICK/NOT SICK

2. Copyright 2007 Seattle/King County EMS Introduction SICK/NOT SICK is a method of rapid patient assessment that helps you make good decisions based on proven clinical indicators. The EMS provider’s chief aim is to decide who is critically ill and who is not.

3. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS New Terms SICK — Someone who appears physiologically unstable as indicated by clinical indicators. Other terms that mean SICK include critical, urgent or unstable.

6. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS Respirations Rate: normal, fast or slow Character: normal, labored, or shallow A patient with shallow respirations, labored breathing, or dyspnea is SICK.

24. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 1— Form a clinical picture.

30. Copyright 2007 Seattle/King County EMS 1—2 SICK or NOT SICK Form a clinical picture. Make a decision

31. Copyright 2007 Seattle/King County EMS 1—2—3 SICK or NOT SICK Form a clinical picture. Take action—go to work. Make a decision

32. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS FAQ What mistakes do people make? Failing to respond to new information Tunnel vision Poor planning

35. Copyright 2007 Seattle/King County EMS Summary SICK/NOT SICK helps you decide who is critically ill and this speeds delivery of care. Formulate three scenarios while en route.

36. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS 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. Copyright 2007 Seattle/King County EMS Questions Dr. Mickey Eisenberg Medical Director Ask the Doc: http://www.emsonline.net/doc.asphttp://www.emsonline.net/doc.asp EMS Online Guidelines and Standing Orders http://www.emsonline.net/downloads.asp Mike Helbock, M.I.C.P., NREMT-P Training Division Manager Email support: help@emsonline.nethelp@emsonline.net