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30 AUGUST 2017 | EMSWORLD.com I t's 0718, the "nursing home hour" for EMS. The day shift has just come to work at Reliable Manor, a facility in your district, and sure enough found a nonresponsive patient. If you've been in EMS for any length of time, you know that early calls to nursing homes are frequent as the new shift arrives, checks on patients and often finds problems. Arriving 10 minutes later, you find an 86-year-old female lying in bed with snoring respirations. She is unarousable by either verbal or painful stimuli; her eyes don't open spontaneously but do with painful stimuli, which causes her to moan. She does not move her hands or arms on command or in response to pain. You note there's a Foley catheter in place, and you touch her skin, which is warm and dry but not hot. The nurse is new to this nursing home—this is her first shift. She's not familiar with this patient or her history. The patient's vital signs are pulse 80 and irregularly irregular, respirations 15 and BP 128/92. Her temperature is 98.2°F. As you wait for the charge nurse to find the patient's chart, you remember the adage "If GCS is less than 8, you must intubate." You start trying to figure her GCS. You know she gets a 2 for eye opening because she opens to pain, but what motor response does she get? She doesn't move her hands or arms but opens her eyes to pain. Is that a motor response or not? In a way it is, but that doesn't fit the GCS chart's descriptions. So does she get a score above 1? You're unsure. She doesn't speak but moans to pain, so you decide to give her a 2 for verbal response. This makes her GCS 5. So do you intubate her? FOUR Score may be an improvement over GCS, but the fact is, they're just not that useful By Steve Cole, NRP, William E. (Gene) Gandy, JD, LP, Steven "Kelly" Grayson, NRP, CCEMT-P, & Jason Kodat, MD, EMT-P Steve Cole is an educator and training captain for a third-service EMS agency in the Northwest. He has been in EMS for over 26 years, and his background includes military medicine, technical rescue and EMS education. His EMS passions include FOAMed, street toxicology and mentorship. William E. "Gene" Gandy , JD, LP, has been a para- medic and EMS educator for over 30 years. He has implemented a two-year associate degree para- medic program for a community college, served as both a volunteer and paid paramedic, and prac- ticed in both rural and urban settings and in the offshore oil industry. He lives in Tucson, Ariz. Steven "Kelly" Grayson , NRP, CCEMT-P, is a critical care paramedic for Acadian Ambulance in Louisiana. He has spent the past 22 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is a frequent EMS con - ference speaker and author of the book En Route: A Paramedic's Stories of Life, Death, and Everything In Between and the popular blog "A Day in the Life of an Ambulance Driver." Jason Kodat , MD, EMT-P, has been in EMS for more than 15 years. He has reviewed EMS textbooks and the USFA's Handbook for EMS Medical Directors, and lectures at regional EMS conferences regularly. He currently works as an emergency physician and associate EMS medical director at hospitals near Pittsburgh, Pa. COMA SCALES: THE GOOD, THE BAD AND THE UGL Y