Jan 7, 2015
A couple of years ago I read a great article by Kelly Grayson on EMS 1 that talked about patient refusals and more specifically a person’s ability to refuse. I liked it so much that I adapted parts of it into a refresher lecture that I did for a couple of years up in Massachusetts. Now, almost five years later when I am back on the street, I still use portions of it as part of my refusal assessment.
Kelly talked about orientation, memory, cognitive ability, and recall as ways to expand upon the old adage of “alert and oriented to person, place, time and events.” On every patient that is going to refuse my care, and often on almost every patient that I do any sort of orientation assessment on there is one simple problem solving question that I ask them: “If I gave you two quarters and a dime, how much money would you have?” The answer, of course, is sixty cents. Easy, right? I’ve run into patients though who were able to tell me who they were, where they were, and when it was, but were not able to answer that question.
It also gives me another leg to stand on if someone misidentifies “time” for whatever reason. I’ve found through the years that time is the one that is most often missed. How many times have you asked a patient, “can you tell me what day it is?” and had them giving you a correct answer that had you looking at your partner for confirmation because you are not completely sure what day it is? I’m a forgetful person, and it happens to me quite often.
Take, for instance, a retired patient, or a patient in a nursing home. Days might blend together for them and while they might be able to correctly identify the year, or tell you what holiday we just had or are going to have, correctly identifying the day of the week, date, or month might not be as easy as one might think. Of course, you might ask a patient for a recent holiday, and have them answer “Christmas” and then ask them the month and have them answer “May!” and have a clear picture of an altered mental status pained for you, but those are unique circumstances.
The questions that we ask our patients should not be easy ones. How many regular diabetic patients are able to be alert and oriented to person, place, and time just based on repetition of them being asked because you encounter them so often, but they are still walking around with a blood sugar of 28, and will exhibit some level of altered mental status if you dug just a little deeper? For example, I encountered a patient once who correctly told me their name, the address they were residing at and told me the day of the week, and then said they were meeting their father for lunch in an hour. He had been dead for fifteen years.
The patient was alert to person, place, and time, but showed signs of impairment requiring intervention.
What I am getting at is it should be easy for a patient to tell you who they are. It should be easy for a patient to tell you where they are, whether its home, the grocery store, or their girlfriend’s house. Time and cognitive ability though are not quite as easy, so always strive to get them to answer two “time” questions to really make sure they have all of their ears turning, and don’t be afraid to ask the “sixty cent question” or something similar to make sure that they they have some simple problem solving ability.