The Art of Questioning - Part 1

 

In the previous articles we have looked at how the Vital Signs can tell us if a casualty is Big Sick or Little Sick and even what the problem is.

All of the vital signs can be assessed in all casualties, conscious or unconscious, but if our casualty is conscious we can get something else - information from them.

On all of our courses, from the basic to the advanced, there are three steps we promote when dealing with all conscious casualties:

  1. Notice the problem
  2. Sit them Down
  3. Ask them questions
     

Notice the problem
Whilst we may be dealing with injuries or illnesses we are primarily dealing with people.   There may be an apparent problem but take the time to notice what the real problem is, from their perspective:

  • A casualty covered in blood may look horrific but it may have come from a simple head wound without serious underlying problems.  It may not be their blood.
     
  • A casualty may be hunched over clutching their chest but before you jump into the Heimlich maneuver or assume it is cardiac arrest, are they choking?  Is it chest pain?  Is it a chest injury?  Is it asthma or anaphylaxis?

Until you notice the casualty's actual problem they will be getting more anxious and less compliant.

Sit them down.
If the casualty is fully alert and breathing normally, a chair is fine.  If they are not fully alert, with breathing difficulty or chest pain, get them to the floor.

Ask them questions
All questions are good; regardless of what the casualty is saying, how they answer will reveal:

Their level or response - are they lucid or confused?

The clarity of their airway - are they speaking easily or do they sound horse or is there difficulty getting words out?

How they are breathing?  If they are able to reply in full sentences they probably don't have a breathing condition.  The casualty's speech will mirror their breathing:  If their breathing is fast and weak their speech will be short words, spoken quickly and quietly.  If their breathing is slow and deep their speech will sound deeper, with longer pauses between each word.

Regardless of what they are saying, noticing how they reply will allow you to assess the R, A and B of the DR<C>ABCDEFG accident procedure.

 

So all questions are good....but some questions are better...

 

SAMPLE

SAMPLE is an acronym which prompts us to ask six basic but important questions which can - even at a very basic level - allow us to work out what the problem is:

 

Symptoms

A sign is something we can see (bruising, swelling, bleeding etc) and we might find these on any casualty if we look properly.  The symptoms are how the casualty feels.  Only a conscious casualty can tell us their symptoms.

Symptoms include (but are not limited to):

  • Pain
  • Nausea
  • Headache
  • Dizziness
  • Heat / Cold
  • Tiredness
  • Irritably
  • Blurred vision

None of these are visible so we will need to ask the casualty.  This may sound obvious but if the casualty has an obvious injury it is easy to become distracted by that injury.  Clearly they are in pain but how else do they feel?

Their symptoms may seem insignificant - they feel tired for example - but is this normal?  Is it normal for the persons age, their general health, what they have been doing or the time of day?

Good questions lead to better questions.  If they feel dizzy or lightheaded, that may be one any number of things which can affect the casualty's Level of Consciousness - but is it normal for them?  If they reply with "I often feel a bit dizzy if I stand up to quickly" that might not be too much to worry about.  If they have never felt like this before or it had been going on for a long time, that might be more concerning.

 

Allergies

Some allergies are will known; peanuts, wasp stings or shell-fish.  Some are less well known.  If the patient replies with: "Yes, Erythromycin".  Do you need to know what that is?  No.

Firstly, no one is expected to have a knowledge of all medical conditions, let alone a First Aid responder.  A Paramedic will have a wider knowledge and a Nurse more so.  As we look at Specialist Nurse Roles and Doctors the depth of their knowledge becomes vast but only within a narrow field.

No one knows everything so don't worry.

Secondly, we may not necessarily need to act on this information; as with the Vital Signs, if this information means nothing to us, we pass on what we have found so someone else can act on them.

Good questions lead to better questions.   If they are allergic to wasp stings, have they been stung?  If they are allergic to nuts, have they eaten recently?

 

Medication

What medication is the casualty taking or has recently taken?  You may be familiar with common medicines and even you may even know what they are for, such as:

  • Ventolin
  • Insulin
  • GTN
  • Warfarin
  • Epi-pen

But what about Gabapentin? Seretide?  Careolol?  The previous clause also applies here; while many people will be familiar with over-the-counter drugs or common medicines no one is expected to all of them or what they do.  If it means nothing to you, make a note of it and pass it on.

Good questions lead to better questions If someone was to say they use an inhaler, further questions may be:

  • Do you need it now?
  • Do you have it with you?
  • When did you last take it?

 

Past Medical History

No one really wants to know about the casualty's fungal nail infection or that they had their tonsils removed when they were 12, but is there anything ongoing that might be relevant.

With injuries; Is this a recurring problem (such as back pain) or is this a new event?   Is this a new injury or have they aggravated an existing injury?  Have they had any surgery in that area?  

With illnesses; Is this something they have had before?  Do they have any medication for it (see above)?  Could their injury (a fall) be related to their illness (hypoglycaemia)?  

 

Last In and Out

Whenever I ask people "Who is affected by low blood sugar?"  the overwhelming answer is "Diabetics!"

Everyone is affected by low blood sugar.  First Aid is not just blood, guts and chainsaws; the casualty's problem may simply be that they have just run out of energy or are dehydrated.  

Low blood sugar can make anyone feel tired, irritable and will eventually affect their LoC.  Casualties with low blood sugar are more susceptible to hypothermia.

Thankfully, low blood sugar is also incredible easy to rule out:  If you can give your casualty something sugary and they quickly recover, you have found the problem.  Now give them something more substantial - complex carbs, protein and fats - to back it up because simple sugars are also used up very quickly.

If the casualty does not improve, at least you rule it out and look further.

If it is not a case of low blood sugar because they tell you they have recently eaten, what did they eat?

We also want to know about how much and when they have eaten, drank and been to the toilet.  In a remote setting this may mean recording urine output.

 

Events

What happened?   This alone can help you build up a bigger picture.  Ideally get this information from the casualty if they are able to.  If not, get it from bystanders but beware; bystanders have a tendency to embellish so listen to what they are saying, look at the scene around the casualty and look at the casualty to build up a representative picture.

 

How to ask these questions

  • The SAMPLE mnemonic is a prompt, not a script.  You do not have to ask the questions in this order and you do not have to use these words.   These questions should be asked conversationally, possibly while you are treating the injury or preparing your kit.  

Your first question as you approach the scene or the casualty will be: "What happened here?" [Events]

possibly followed by  "And how are you feeling?" [Symptoms]

"Has this happened before?" [Past Medical History]

"Are you taking anything for that?" [Medication]

"When was the last time you ate?  What was it?" [Last in and Out]

"Do you have any allergies?" [Allergies]

  • Be careful of asking leading questions which influence the casualty such as "I bet it's painful, isn't it?" or "You're eating properly, aren't you?"
     
  • Get the questions out of the casualty early.  Once the casualty goes unconscious you have lost your opportunity.
     
  • Even if the answers aren't particularity revealing ("No, it's never happened before, I don't have any allergies and I'm not on any medication")  at least you now know this rather than assuming and this information is also passed on.
     
  • Good questioning is, if nothing else, distraction for the casualty.  One of the few non-pharmaceutical methods of pain relief we have.

 

Your turn

With the information provided, work out what the following 6 basic medical issues are: