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32 AUGUST 2017 | EMSWORLD.com because this is the criterion most variable and affected by extrinsic or chronic factors. Also interesting is the way the FOUR Score accounts for patients who are intubated or ventilated. It distinguishes between the completely apneic patient and one who is ventilated but still has some respiratory effort or response. This makes a lot of sense to me! Gandy: Jason, what are your thoughts about the FOUR Score versus the GCS? Would you learn anything different from one of them versus the other in the first report from a medic? Kodat: A medic giving me a FOUR Score report is telling me they're keeping up with the literature, and since the recommended test for blink reflex is dropping saline into the eye from 4–6 inches, successfully doing so tells me more about the medic's eye-hand coordination than it does any- thing else. But I don't want to know about the medic right then—what I really want to hear about an individual patient is a decent neurologic exam. Gandy: I agree. I teach my students to do a neurologic exam in less than one minute. It's easy to do, and it says volumes more than a numerical scale. And in fact, when I say to an emergency physician, "Doc, my patient is awake and talking to me appropri- ately," doesn't that tell her what she needs to know in 10 words? If I were to say, "Doc, my patient is talking to me but not mak- ing any sense whatsoever, and she doesn't follow commands," does that not tell him more than "Doc, my patient is a GCS 11!"? I think GCS is for long-term tracking, not for immediately meaningful information at the time of injury or illness. To me it's much better to say, "Doc, when we got on scene, she was talking to me and making sense, but now she only responds when I pinch her trapezius, and that is with a groan." I have painted a picture for the physician, not given a score. Which is more meaningful? Kelly, as a medic, do you think it's impor- tant to calculate a GCS early in your evalu- ation and treatment of a trauma patient, or can it wait? Grayson: I think it's important for risk managers and people who run QA reports without reading the narrative section. But since my run reports get returned if GCS isn't documented and my yearly raises are partly based upon my ePCR accuracy, it is important to me. But clinically? Not so much. I'd venture to say any competent EMT can tell when a patient is in extremis without stopping to calculate a GCS. Assessment of GCS is one of those automatic and intuitive things where you note a finding mentally without giving it much thought and recall it for documentation purposes later, in much the same way that you don't really need a blood pressure cuff when you're kneeling over a critical trauma patient on a scene—all you have to know is what the GCS isn't. You can calculate what it is on the way to the hospital or later when you're doing your PCR. Gandy: Steve, how does the FOUR Score work with medical patients such as stroke patients or those with acute subarachnoid hemorrhage or epidural or subdural bleeds? Cole: A 2012 study assessed the use of FOUR Score in stroke patients. It compared favorably with other scales such as the GCS. Another 2015 study compared the FOUR Score to the GCS in more than 1,000 CCU/ ICU patients, also with favorable results. Most interesting is a 2016 study of 80 criti- cally ill TBI patients in which FOUR Score not only compared to GCS but seemed to outperform the more intensive APACHE II Figure 2: FOUR Score—Full Outline of UnResponsiveness Response Score Eye opening Eyelids open or opened, tracking or blinking to command 4 Eyelids open but not tracking 3 Eyelids closed but open to loud voice 2 Eyelids closed but open to pain 1 Eyelids remain closed with pain 0 Motor response Thumbs-up, fist or peace sign 4 Localizing to pain 3 Flexion response to pain 2 Extension response to pain 1 No response to pain or generalized myoclonus status 0 Brain stem reflexes Pupil and corneal reflexes present 4 One pupil wide and fixed 3 Pupil or corneal reflexes absent 2 Pupil and corneal reflexes absent 1 Absent pupil, corneal and cough reflex 0 Respiration Not intubated, regular breathing pattern 4 Not intubated, Cheyne-Stokes breathing pattern 3 Not intubated, irregular breathing 2 Breathes above ventilator rate 1 Breathes at ventilator rate or apneic 0