Tips for respiratory assessment and just-in-time education

Taking a role as a field trainer is no simple task. Many EMS services give the nod to strong, experienced EMTs and paramedics and expect that good clinical skills will directly translate to effective teaching strategies. While some trainees may be clinically savvy and simply need direction, some new hires require far more intensive assistance and a department's strongest clinician may not be a natural teacher.

The difficulties of being a trainer
There are a few particular difficulties faced by both new and experienced field trainers. First, there is a desire to mold every trainee into a newer version of yourself. While you may be a great clinician, there are many ways to accomplish the goal of providing safe, effective patient care and being a carbon copy of your trainer isn't necessarily one of those steps.

Remember that you have countless individual experiences that have shaped the type of provider you are today and you likely approach calls differently today than you did at the beginning of your career. A brand new EMT or paramedic simply can't be a carbon copy because he or she doesn't have your breadth of experience.

One potential approach, in conjunction with your agency leadership and medical director, is to develop an understanding of the measurements for success in your field training program. For instance, it could be as simple as identifying objectives that a new hire should be able to do:

• Know the protocols
• Perform an assessment
• Build a differential diagnosis
• Design and execute a treatment plan
• Document assessment and care

By designing objectives in this way, a new hire can be evaluated on his or her ability to practice medicine broadly without staying in the training program until trauma, STEMI, stroke and cardiac arrest all get checked off the to-do list. This approach requires faith by the trainer and agency that a provider with those skills and knowledge of the protocols can make good treatment decisions when faced with a new situation.

A second difficulty faced by trainers in the EMS environment is how far to let a trainee go down the wrong path before intervening. There are obviously situations which would pose a patient safety risk, and in such instances the trainer must step in quickly.

In other cases, however, the call may simply not be moving fast enough or a trainee may make a small mistake. It is important to remember that providers learn from their mistakes and as long as an immediate safety issue isn't present, there is educational benefit to letting small problems play out. This gives the trainee an opportunity to recognize and correct mistakes and give insight into how he or she responds to challenging situations. A trainer should not be too quick to jump in if a patient safety concern does not exist.

Coaching in the moment
Once the decision to intervene is made, the trainer needs to understand how best to provide coaching. Obviously a potentially serious medication error should be handled differently than forgetting to check a blood glucose on a patient complaining of dizziness with no diabetic history.

A new EMS provider may feel self-conscious or lack confidence. Abruptly jumping in with a dismissive or rude comment likely won't result in a lesson learned and may further distance the trainee.

In the patient case, a man with shortness of breath, the trainer starts off on the right path, asking the trainee to review common causes of respiratory distress while responding. From there the call heads downhill quickly. Dismissive or diminutive comments are common and the approach isn't so much one of guidance as it is hazing.

A more productive approach would have been to suggest particular assessments or treatments in an attempt to jog the trainee's memory. Often trainees can be guided back onto the correct path by breaking the cycle of questioning which has led them astray.

Basic respiratory assessment
The goal of the respiratory assessment should be to identify the underlying cause of the shortness of breath. In this case, the patient has a history of recent weight gain and a productive cough along with hypertension and hypoxia. Kristen has clearly gotten off track and seems to be focused on a potential COPD exacerbation given Steve's history as a smoker. COPD is certainly one potential cause but there are others which are more likely. Rather than belaboring the smoking question, Kristen should focus on the onset of Steve's respiratory distress, the nature of his cough and sputum it is producing and what his lungs sound like.

Another tip for respiratory assessment is to limit the number of open-ended questions. Family or other bystanders may be able to answer some questions and asking questions of the patient which can be answered by nodding yes or no or with hand gestures may keep them from feeling more short of breath.

Building a differential diagnosis
In this instance there are two potential causes of Steve's shortness of breath: CHF and COPD. While Steve does not report a history of either diagnosis, many patients have a history of both and being able to differentiate between the two is key to treatment decisions.

Lung sounds are one potential clue with rales (bubbling) often associated with CHF and wheezes often associated with COPD. In some cases, however, CHF may present with wheezes as well. Steve's recent weight gain and hypertension certainly suggest CHF. As the heart stops pumping effectively, fluid is retained and backs up in the extremities as well as the lungs.

A productive cough is also an important finding particularly if there is a report of sputum type and color. Yellow or green sputum may be associated with an infection — particularly in the presence of a fever —while pink sputum may be associated with fluid retention and CHF.

Based on the limited information collected by Kristen, CHF still seems to be the most appropriate working diagnosis. Providing this summary to her and asking her to work to confirm that diagnosis may help guide the remainder of her assessment and get her back on track.

Case conclusion
You realize quickly that your coaching of Kristen on this call has been misdirected. You mention that the rapid weight gain, hypertension and gradual onset of symptoms seem to point to CHF as an underlying cause. You ask Kristen to work to confirm that diagnosis and to build a treatment plan.

Kristen thinks for a moment and immediately listens to Steve's lungs. "I can hear rales in both bases," Kristen reports. She then kneels down and checks for edema in Steve's legs finding pitting on both lower legs.

Kristen turns to the firefighter and asks him to set up CPAP and then asks you to confirm the ETA for the ALS intercept. She seems to be back on track.

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