You’re called to a 68yom with an onset of facial droop while at rest in church. It’s your partners’ job so you sit back and observe their assessments, diligently listening without interrupting.
“Now give me a nice big smile”, they say. You then cry a little inside…
Neurological assessment is done poorly in the prehospital domain, predominantly because it’s poorly taught, and secondarily because it doesn’t make a significant difference to 98% of the cases we go to. However, it’s no excuse for doing a poor job, and we should consider that poor assessment technique is actually altering our examination findings.
The FAST technique was a tools designed for quick and easy layperson assessment of stroke. The EMT training, and our clinical procedures all instruct us to ask the patient to smile, and assess the facial symmetry. Facial droop should be assessed by: first impressions (at rest), asking the patient to lift their eyebrows, and getting them to show you their teeth. The ‘S’ is for speech, not smile.
Unfortunately, the bodies limbic system is responsible for many things including emotional regulation, and there’s a bit of a risk that in asking patients to smile, we activate the limbic system, allowing for activation of the muscles which have been impacted by a cerebral injury.
With this in mind, perhaps we should think about our neurological exam… it should be simple to do a better job than we currently do. I use a bit a four section method, and tailor the assessment.
Assess the senses- does anything look different, and is the pupillary response normal? Taste, smell, hearing.
Assess the motor response- equal strength in all limbs, equal control of all limbs, sensation in all the areas you’re assessing strength.
Assess mobility- gait, rombergs test, and pronator drift
Assess cognition- memory, understanding, and logic.
In short, just consider how you’re assessing people. It’s likely you can do it better, you can lift your assessment standard, and will be able to make better decisions based on your professional standard. A good neuro exam by paramedics has the capacity to catch a lot of conditions and decrease time to diagnosis, and ultimately treatment. Or, if you’re doing well already… keep doing a wonderful job- just don’t ask patient’s to smile!
Here’s a link that describes neuro obs, if you wanted a different write up on industry standard from nursing. If you wanted to skip mine, this would be my number one replacement…
Edit: References not originally published with this article, my apologies.
Kappos, L., Mehling, M. (2010) Dissociation of Voluntary and Emotional Innervation after Stroke. New England Journal of Medicine 363 (25)
Lezak, M. (1995) Behavioural Geography of the Brain. Neuropsychological Assessment. Oxford University Press: USA
Nichol, D., Appleton., J. (2015) Clinical Neurology: why this still matters in the 20th Century. Journal of Neurology, Neurosurgery & Psychiatry. doi:10.1136/jnnp-2013-306881 229
Herzberg, M., Boy, S., Hölscher, T.,Ertl, M., Zimmermann, M.,Ittner, K., Pemmerl, J.,Pels, H., et al. (2014) Prehospital stroke diagnostics based on neurological examination and transcranial ultrasound. Critical Ultrasound Journal 6 (3) DOI: 10.1186/2036-7902-6-3