DOs and DON’Ts

By Charly D. Miller, Paramedic
EMS Author & Educator, Consultant
Restraint Asphyxia Expert Witness

Learning about the medications your patient takes is vital. Medication information can provide important clues to the patient's past medical history, direct you to explore problems that might be “side effects” from medications (such as dehydration or electrolyte problems secondary to diuretic use), and assists your evaluation of the patient’s current complaint.

But pay close attention to how you ask the patient about medications. Throughout medical history, experienced care providers have been asking “crappy” medication questions — ones that routinely yield incomplete information. Incomplete information leads to medical treatment errors. And, that’s a “crappy” thing, isn’t it?!

One of the most common crappy medication questions is, "Do you take medications prescribed by a doctor?" (Even the open-ended-question-version of that question is crappy: "What medications do you take that are prescribed by a doctor?") In response to such a question, patients are entirely unlikely to report the over-the-counter medications they take; such as daily aspirin ("I saw on TV that it would decrease my risk of heart attack, so I started taking it."), multiple non-prescription inhalers, or gallons of antacid. Medications that aren’t prescribed by a doctor are just as important to a person’s health and well-being, just as indicative of medical problems, and just as important to emergency medical care considerations.

Another frequently-asked crappy medication questions is, "What medications do you take every day?" (See? Open-ended, but still crappy.) The patient will probably tell you exactly that, and only that. If you ask that question, the patient likely will not tell you about taking an occasional nitroglycerin tablet, or getting immunosuppressant therapy everyother day, or being injected with antipsychotic medications every three or four weeks. Not all medications are taken “every day.” Yet, all are just as important to medical history and emergency care considerations.

There are many other similarly “crappy” medication questions. Thankfully, I’m not going to waste print exposing them. Instead, I’ll simply share with you a 4-question system for determining almost all the information you really need to know about any patient’s medications.

Medication Question Number One: Ask the patient, "What medications do you take?" That’s it! "What medications do you take?" Then, note what medications the patient reports.

Medication Question Number Two: Ask, "What other medications are you taking?" Especially when patients take several medications, they tend to stop reciting them long before the list is completed. Or they forget to mention one or four of them. If you stop your medication-questioning after the patient has listed two or three medications, and go on to another line of questioning, your patient is not going to correct you! You’ll rarely (if ever) hear, "Oh! Excuse me, but I haven’t finished telling you about all my medications!"

You must keep asking, "What other medications do you take?""What else?""What else?" until you're sure that you’ve obtained a complete list. (“That’s it! I swear it! Those are all the medications I take!”)

Medication Question Number Three: "What medications are you supposed to be taking, but aren't?”

Medications are expensive. When a prescription runs out, and the patient doesn’t have the money to refill it — or doesn’t want to spend his money getting a medication refill when it’s needed — he may stop taking the medication.

Many people find the odor and taste of potassium extremely offensive. So, they keep taking their Lasix, but stop taking their potassium.

When traveling, a patient may decide to stop taking his diuretic because he doesn’t want to have to stop traveling and pee every 15 minutes!

Or, after using the grocery store’s machine to check his blood pressure for a couple weeks, and finding it identified as “normal” (both times), a patient may stop taking his antihypertensive medication. ("Well! My blood pressure’s normal now!”)

For whatever reason they do it, patients may stop taking medications when they shouldn’t. And they rarely ever tell anyone about it. When a patient isn’t taking all the medications he’s supposed to be taking, you need to know about! Is his emergency related to not taking his medicine?

When they list their medications for you, patients may or may not include the medications they’re supposed to be taking but aren’t. So, no matter what medications they’ve listed, it’s important for you to ask, "What medications are you supposed to be taking, but aren't?"

You may or may not get an honest answer to that question. (No matter what reason they’ve used to “justify” stopping their meds, underneath it all, patients know that they shouldn’t stop taking them without being told to!) But, certainly, if the patient admits to not taking one drug he’s supposed to be taking, remember to ask, "What other medications are you supposed to be taking, but aren't?"

And keep asking, "What else?""What else?" … until the patient insists that, “That’s it! Those are the only medications I’m supposed to be taking, but aren’t!”

Medication Question Number Four: "What medications are you taking in a way that is different from how you were told to take them?" Patients may be taking their medications, but if they’re not taking them the way they’re supposed to be, the medications won’t effect them the way they’re supposed to. This question identifies underdoses, overdoses, and otherwise-nontherapeutic uses.

Sometimes, in order to save money, patients take only half the prescribed dose of a medication. If the prescribed dose of a medication isn’t alleviating their problem, they may take extra doses. Or (for whatever reason), they’ll take them at times other than when they’re supposed to. ("I take my nitroglycerin whenever I start to feel light-headed.") You need to know about such medication-taking alterations. (Especially since the patient’s physician probably has no idea that the patient has altered his medication regimen.)

"What else?""What else?"!!!

There are tons of other medication questions that patients could (and often should) be asked. Questions about Meds they’ve just started … just stopped (under orders to do so or not) … “vitamins” they take … and so on. But, by learning to routinely use at least these Four Medication Questions, and learning the basic interview techniques identified in this program, medical care providers quickly realize how to create their own, “Magic Med Questions,” based upon individual patients’ needs!

Once you know the patient’s meds, there is one more step:
Have someone LOOK THEM UP!

Only an android with unlimited capacity for data storage and retrieval could possibly memorize every patient-administered medication, its frequent side effects, effects of overdosage, and its special potential for adverse or altered interaction with prehospital-administered medications. Consequently, unless you own and USE a pocket reference that will supply you with this information, you may be risking violation of the EMS prime directive; to DO NO HARM. At the very least, you will remain uninformed about the patient’s medical history (as provided by their medications), and you may be unprepared to deal with unexpected patient reactions to the medications you administer.
The pocket reference you elect to buy needs to be one that will not interfere with your “attention to business” (i.e., critical patient assessment, airway management, and patient care needs). You should be able to hand-off the reference book, to any person on scene, saying “Please look up this drug for me, read to me what it says, and then give me back my book. Thank you.” This means that the reference book must be one that enables a non-medical participant (the patient’s spouse, a police officer, any person who can read English) to access the information for you.

When using ANY Pocket Drug Reference, if someone looks up a drug for you but can’t find it in your guide, be sure you keep the missing drug’s name written down somewhere. As soon as you can, look up that drug in the best patient medication reference there is: Drug Facts and Comparisons. The hospital pharmacist (or any other pharmacist) should have a subscription to that reference.
[The common drug references found in emergency departments (such as the AHFS Drug Formulary or the PDR) are little better than drug “advertisements!” They won’t have the most accurate, complete, or up-to-date information.]

Read through the drug’s information, making notes of the points specifically important to prehospital assessment and care, such as;

When you have the opportunity to do it neatly, write the drug’s information in your pocket reference, providing an entry for each name in alphabetical order.
The SANFORD Sharpie® ULTRA FINE POINT permanent marker works well on plastic polymer texts.

  1. What medications do you take?
  2. What other medications do you take? … What else? … What else?
  3. What medications are you supposed to be taking, but aren't?
    … What else? … What else?
  4. What medications are you taking in a way that is different from how you were
    TOLD to take them? … What else? … What else?
  5. Lastly: Have someone LOOK THEM UP and tell you what they are for!

for my Medication Question Secrets presentation, click below:
Medication Question Secrets.

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