Hello, I'm here today with Dr. Mahadevan from Stanford University. Welcome, Dr. Maha. Hello. Thank you for joining me. Let's discuss how to approach a new patient or a patient whose condition has changed significantly and unexpectedly, where the severity of illness and the cause of illness are unknown. Whether in the emergency department, clinic, or hospital, when we first see a new patient or a patient whose condition has worsened unexpectedly, we must rapidly do three things at the same time. These three things are evaluate the patient for the cause and severity of their illness, think whether the patient is currently sick or whether they may become sick very soon in a matter of minutes to hours, and act, begin stabilizing patients we categorize as possibly sick. Therefore, our approach to an unknown or undifferentiated patient is different than how we approach a known patient in the community, clinic, or hospital. In the unknown patient, we evaluate patients, think about the cause and severity of their illness, and begin to treat and stabilize patients all at the same time, before we know exactly the cause of the patient's illness. When doing multiple things at the same time, it is very important to use a systematic approach to the evaluation, one where we do the same thing with each patient. This helps us avoid forgetting things and missing important findings. As we approach our patient, we pick up on many clues that tell us whether or not the patient appears sick. Looking at a patient's general appearance is very helpful in determining if they are sick. It is not perfect however. Therefore, after looking at their general appearance, we go through a brief evaluation that we should repeat on almost every patient. Dr. Maha, what are the things you look for when evaluating the general appearance of a patient? Well, I look whether the patient is chronically ill or healthy appearing, and I also looked for signs of anxiety, sleepiness, respiratory fatigue, and diaphoresis, which also means sweatiness. After we assess general appearance, we then go through a brief evaluation beginning with a very rapid assessment of a patient's level of consciousness using the AVPU categorization system. AVPU stands for alert, verbal (responds to voice), pain (responds only to painful stimuli), and unresponsive. Dr. Maha, how do you like to assess each of these AVPU categories? When assessing whether a patient is alert, I like to see if their eyes are open and if they are paying attention to their environment and things such as the physician, myself. Then, if they're not clearly paying attention to their surroundings, I greet them with a hello and if they respond to my voice, then I categorize them as verbally responsive. Next, if they don't respond to my voice, I try to provide some non-harmful, painful stimuli, like I might pinch the nail of their thumb or do a rub with my knuckle on their sternum to see if they respond. If they don't respond to two attempts at painful stimuli, I categorize them as unresponsive. For those patients I categorize as P, that is responding only to painful stimuli, and those that are unresponsive, I categorize them in my mind as sick. Once we perform the AVPU assessment of consciousness, we begin assessing the ABCs or airway, breathing, circulation. If the patient is speaking normally, consider the airway open and clear. If they are not speaking clearly, then you can check their airway by looking inside their mouth. After checking their airway and removing any obvious obstruction, you assess a patient's breathing. Dr. Maha, how do you typically assess breathing? I look for a rapid respiratory rate that's usually greater than 25 breaths per minute, tripod positioning if the patient is sitting upright, chest heaving, gasping, and contraction of their neck musculature, and sometimes their abdomen pulling in with each respiration. Patients don't always have a rapid respiratory rate however, and if they're in distress for a long period of time, they can begin to get tired or fatigued and their respiratory rate can begin to slow down. At this point, they begin looking tired or even sleepy. If you are concerned about a patient's breathing, position them correctly and apply oxygen. After assessing and supporting breathing, do a rapid circulation assessment. Start by checking a pulse in the wrist. If the pulse is very rapid or weak, this is concerning. If you cannot feel a pulse in the wrist, check a more central pulse in the neck or the groin. If you cannot feel a pulse anywhere, call for help immediately. If there is anything abnormal found on airway, breathing, or circulation assessment, categorize the patient as likely sick. Dr. Maha, which vital signs do you like to get early in the patient's evaluation? I like to get all five vital signs early on and that would include the heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature. Summarizing our rapid evaluation, we look at the patient's general appearance as we approach them, check their consciousness using AVPU scale, perform an airway, breathing, circulation assessment, and get a full set of vital signs. Because we are using a systematic approach to evaluating the patient, this allows us the ability to think about the patient at the same time. Dr. Maha, what are you trying to determine as you think about a patient early in their course? I really try to classify if the patient is possibly sick versus not sick. And to clarify, when I'm thinking about patients as sick versus not sick, I like to think about whether they are at risk of dying or becoming more ill in the next minutes to hours to days. I'm really not focused on whether they have a long-term medical condition that may harm them over months to years. During the evaluation we do takes an early steps if we find the patient has worrisome abnormalities on their initial evaluation. Dr. Maha, what are some early actions you take to stabilize patients even before you know exactly what may be causing their illness or even how ill they are? There are many rapid interventions you can do to help resuscitate and stabilize the patient early on. I like to focus on gathering resources by calling for help, properly positioning the patient to improve their breathing and perfusion, providing supplemental oxygen, and establishing an intravenous line. Let's summarize. We have to rapidly evaluate, think, and act on patients that are new to us and we do not know if they are sick, and those patients that we may know but have gotten significantly worse. However, we are going to do these things simultaneously, meaning at the same time. We categorize the patients into possibly sick or not sick. As we continue caring for the patient, we continue to recheck them because their condition may change. When checking them, we continue to use the evaluate, think, act approach. Thank you, Dr. Maha, for joining us. Do you have any final learning points? Yes, thank you. Remember, listen carefully to your patients. If they're telling you something is wrong, it usually is. Build trust by listening to them, expressing concern and care for them, and trying to be helpful. And lastly, do not forget, stable patients may become unstable. Therefore, it's really important to continue to check and recheck your patients, especially after any interventions. Thank you very much.
