SAMPLE is Dead

By Dan Limmer

EMTs have been taught a SAMPLE history for some time. While it is an easy mnemonic, it has evolved into a rote process for conducting an assessment. It is time to shed our dependence on the SAMPLE history and use a more mature and appropriate process for history and physical examination.

Old timers will remember that the traditional medical AMPLE mnemonic was in widespread use prior to the 1994 EMT-B curriculum release. At that point the “S” was added. In combination with a RIP SAMPLEcurriculum that was widely regarded as “watered down,” the entire history and physical examination for the EMT suffered a mindless deterioration.

I’m not opposed to easy.  But I don’t like EMTs getting out of class and passing the exam but not feeling secure in the back of the ambulance. Class after class would ask their instructor, “How will I know what to say or do when I get into the back of an ambulance?”

For some, the secondary assessment portion of the old NREMT medical patient assessment practical station became a simple reciting of the SAMPLE history and “a few other things to show you assessed something.” The physical exam was a one-point check box. This is so wrong.

This failure is caused by our dependence on the SAMPLE history as something more than a mnemonic. Somehow it became our assessment. While the history is of great value in the medical patient, it isn’t the only thing. And it should be a thinking process.

The National EMS Education Standards provides the mature approach we are looking for. The approach we really need. It is based on a foundation of pathophysiology and involves an assessment of body systems (much like the medical model). This is supported in the new NREMT skill sheets with a 5-point value for body system exams. If a patient has chest discomfort or respiratory distress, the EMT can assess those systems. In an altered mental status presentation, the EMT will have an educational background to assess a variety of possible systems.

Difference between the old and new assessment theories.

An EMT approaches a 72-year-old female patient with difficulty breathing. The patient is sitting on the edge of her bed in the tripod position and has 2 – 3 word dyspnea. The distress came on that afternoon and is severe. Oxygen is administered based on the level of distress and pulse oximetry readings as part of a good primary assessment.

The patient reports minimal significant medical history–just allergies—for which she was recently prescribed the medications on the dresser. The EMT finds Nasonex and Combivent.

So the EMT finds respiratory distress and a medication that is prescribed to the patient for respiratory distress. This appears to be a 1994 EMT-B “no brainer” to assist the patient with the medication.

But what if the patient’s respiratory distress isn’t caused by bronchoconstriction?

I was on this call. As a paramedic I did a respiratory and cardiac work-up and found pedal edema, orthopnea, weight gain, rales and dyspnea on exertion. It was heart failure.

The point of this is not to extoll my personal experience—or even to play up paramedics. Why? Because an EMT should now know how to perform a basic cardiac and respiratory work-up and come to the same conclusion I did. No advanced skills were necessary to determine that this wasn’t a case of allergies or reactive airways.

It turns out that the patient had been developing heart failure and went to the doctor for “wheezing.” The doc went the allergy route (rather than the wheezing of cardiac asthma) and prescribed the medications. It happens. This was an otherwise very healthy 72-year-old woman.

EMT-Bs trained under the 1994 curriculum may have looked at this as an opportunity to assist the patient with their inhaler. More and more EMTs are carrying small volume nebulizers on the rig. Some carry CPAP, intranasal medications and more. As the EMT’s toolbox gets bigger, the need for thinking (and solid assessment on which to base that thinking) increases.

This situation shows the difference between a rote SAMPLE history (really a simple matching exercise) and a true physical examination process. I’m happy to say that the EMS education standards can take us away from this rote process into the realm of thinking—if we let it.

If SAMPLE should be downplayed and we need a more thought-based method of assessment, how is that process taught?

There is no easy answer. It will take a major paradigm shift to truly make the necessary changes–and the biggest changes will rest on the shoulder of the educators. The following 5 tips span the spectrum of education from lecture to skills to testing.

5 Tips for Integrating Patient Assessment in the Classroom

  1. Integrate some pathophysiology into every lecture. This is the difference between students memorizing list of signs and symptoms and students understanding and predicting signs and symptoms.
  2. Use a complaint-based approach in your classes. Label your sessions by complaints—not conditions or “emergencies.” It is a small thing but it sets a tone. Then start each lecture broadly and work into greater detail. This is the same approach used with patients in the field.
  3. Teach differential diagnosis. Even though EMTs won’t diagnose in traditional terms, the process is valuable to help them consider the possibilities. This will help them determine what to examine for. Even by thinking of the possible body system involved your students will have a direction for assessment. In the case where EMTs have intervention choices (small volume nebs, CPAP, naloxone are just some of the things EMTs are doing in some areas) their decisions will be more accurate.
  4. Reduce your lecture time by at least 10% and integrate case-based scenarios. (I actually think 10% is low but didn’t want to scare you.) We need students out of their seats and thinking/practicing more.
  5. Beef up your exams (both written and practical) to include more scenario-based decision-making questions. If students know it is expected of them they will take it more seriously in class.

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