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EMSWORLD.com | APRIL 2016 45 information from caregivers or witnesses, checking for medical alert bracelets or wallet cards, and utiliz- ing diagnostic tools (such as vital signs, SpO 2 , SpCO, EtCO 2 , ECG [both II- and 12-lead] and glucose) may provide you with valuable information. To be proficient in conducting the history and physical, your process must be organized and sys- tematic. Practice makes perfect. Utilize the following outline as a guide for neurological assessments and a template for writing patient care reports: 1. Chief complaint—The main reason 9-1-1 was called; 2. History » Histor y of the present illness, including OPQRSTA » Past medical history » Medications » Medication allergies » Social history » Family history; 3. Review of systems—In general, when conduct- ing a focused neurological exam, the following body systems should be reviewed, as they are most likely to provide the most information regarding neurological emergencies. » General: Look for recent illness, fever/chills, petechial rash » HEENT: Look for headache (worst headache of life), head trauma, changes in hearing, vision loss, blurred or double vision, photophobia » Cardiovascular: Look for syncope, palpitations » Neurological: Look for difficulty speaking or understanding speech, unilateral weakness, dizzi- ness, seizure, paresthesia, difficulty with coordina- tion, loss of balance; 4. Physical exam » Vital signs » Stroke assessment tool (Cincinnati, LAMS, MEND, etc.) » Mental status » Speech » Cranial nerves » Cerebellar function » Motor function » Sensory function; 5. Prehospital diagnosis and differential diagnosis. Physical Exam Before we discuss the specifics of a neurological exam, let's consider the logistics of conducting a physical exam. Today many agencies have more than one para- medic on a unit. That's both good and bad news. When more than one paramedic is on scene, often no one is in charge because everyone is in charge. This is confusing for the crew as well as the patient. To bring some calm to the chaos, many agencies have adopted the "pit crew" concept. The pit crew is an organized team approach to patient care and an efficient way to utilize personnel in order to maximize care and minimize treatment and transport times. Beginning each shift, patient care responsibilities should be divided up among the crew. Responsibili- ties will depend on the number of personnel and their level of training (see sidebar). Vital Signs Stroke patients frequently present with a reflex hyper- tension. Emergently lowering the blood pressure can be harmful in an ischemic stroke since it will decrease cerebral perfusion to the ischemic brain, resulting in a larger stroke. However, hemorrhagic strokes may require a decrease in blood pressure to slow bleed- ing. A CT scan needs to be obtained prior to making a decision on blood pressure treatment. Therefore, treatment of stroke-associated high blood pressure is not generally something to be addressed in the prehospital setting. Stroke Assessment Tool In most scenarios the history comes first. However, when there is suspicion that a stroke alert may be present (based upon the caller's chief complaint to dispatch), the need to obtain a stroke assessment within the first several minutes of patient contact trumps the need for obtaining history. Because "time is brain," neurological exams begin with the stroke assessment tool adopted by your agency. Once a stroke is identified, rapid transport to a stroke center is more important than staying on scene to conduct additional T h e P i t C r e w A p p r o a c h Just like the pit crew for a race car driver acts rapidly as a team to effi- ciently get the car back to racing, the pit crew method in EMS allows a crew to rapidly assess and begin the stabilization, treatment and transport of patients with life-threatening illness or injury. For example, in the case of cardiac arrest, depending upon the number of crew available, one crew member should be assigned to begin chest com- pressions within 30 seconds of patient contact, one wields the moni- tor/defibrillator, one manages the airway, and another administers the medications. In the case of a chief complaint possibly consistent with a stroke, one team member should have been assigned to perform a rapid stroke assessment within the first few minutes of patient contact to determine if a stroke alert is present. Other team members can gather critical medical history, especially the time the patient was last known to be normal, plus medications, allergies, etc. To minimize on-scene time for critically ill stroke patients, calling a stroke alert on eligible patients within the first few minutes of contact should be the goal of the pit crew method.