Think Like A Detective: Hacks To Improve Your History-Taking [PT2]

Pulsara's Chief Growth Officer, Kris Kaull, recently had the opportunity to sit down with Rob Lawrence on the EMS One-Stop podcast. In this episode, Rob talks with Kris about history taking and how to improve communication and gather better intel. Kris shares his top 10 hacks to improve your history taking, including thinking like a detective, thinking outside the box, understanding medical medicine, being a good listener, and more.

This podcast originally aired on EMS One-Stop on November 17, 2022. Check out part 1 of our blog coverage here, and then listen to the podcast and check out the full transcript of part 2 below.

(Continued from Part 1) 

NOTE: This transcript has been edited for brevity and clarity.

Kris Kaull

The next history-taking hack is number five: you need to have an understanding of medicine. My favorite words of wisdom—and I had a lot of them—one word of wisdom is that if you’re starting out in EMS or you've been doing it for 20 years, one thing that I was told very early on in my career, and I would implore you now because it's so easy to do it, much easier now than it was back then, is that after every call, read something about that call. I recently flew a patient that was bitten by a rattlesnake. And yes, we have all these basic things: don't suck the poison, don't do big tourniquets, mobilize it. But like, the hemodynamic challenges with a patient who was bitten by the rattlesnake, and I was like, "Wow, what is going on, this is crazy." And I read and read and read about it after the call. And so if you do that, imagine after every call you just read one thing about that case, you're going to be that much better of a clinician over the next month, over the next weeks, over the next few years. And that's where we say, oh, all this experience and training.

So history-taking hack number five, very succinctly, is understanding medical medicine. Think about that person who fainted. How often have we gone to somebody who just fainted, and we asked them questions, and they're like, "I'm feeling good. No chest pain, no difficulty breathing. I'm okay. I just want to go back. Maybe I'm just too hot, or I haven't drank water, I haven't eaten." And they're giving you all these little reasons. And how often have we said, "Okay, well, if you don't want to go, call us back later, sign this refusal."

And yet that's the difference between a physician and us, right? A physician looks at their medical textbook, and they have column after column of just a list: One column, two columns; page two: column three, column four; page three, column five, column six; page four. They have eight columns of all the reasons why that person could have fainted.

And when they dig in, how many of those syncopal episodes could be fatal? And by just asking a couple more questions, they can rule out a lot of those. And so it's not, “Oh, I fainted. I feel good,” and you're fine. It’s, “You fainted, and you say you feel good. Let me ask more medical questions because I'm thinking of all the reasons why somebody can have a syncopal episode, and many of them are very serious. And I want to make sure that we rule those out.”

Rob Lawrence

Medical medicine. You've just planted that in my ear, Kris, because one of the things I'm working on right now is an article on what Dr. Seuss learned at med school. And, of course, it's all about alliteration and repetition. So thank you for medical medicine. I'm going to use that as a go-forward.

Kris Kaull

So you have Dr. Seuss alliterations and medicine? Do you have any of these started? Can you share?

Rob Lawrence

Yeah. So I've written one about acronyms. And here you go, so this is the world premiere of this particular poem.

A menu of medical, medical soup

Confuses the layman;

Throws some for a loop.

STEMI and MRSA,

Rhabdo, REBOA.

CPAP to C-diff,

ECMO, Ebola.

COVID and SALAD,

CABG and hives.

Munchausen by proxy.

CPR, saving lives.

There we are. That's my opening. 

Kris Kaull

This is fantastic. I love this.

Rob Lawrence

You know, that great philosopher Elmo once said, "it's incredible where you can go in your imagination." And that's why I love writing and being creative. Sorry, we're going totally off track. Let's go back into history.

Kris Kaull

Rob, these are fantastic! Well, you're bringing color and commentary to this. So our history-taking hack number six talks about all the types of ways we can communicate. Think about communicating one-on-one. And then in that one college-level class, or in high school or grammar school, you learn public speaking, or to speak and present in front of the classroom. 

You have a reading class, and you might have a writing class, but you know what we don't have, Rob? A listening class. And listening is different than hearing. Hearing is continuous, it's natural, it's passive—but listening is intermittent. It's learned, it's active, it requires concentration, and you have to choose to participate.

Rob Lawrence

It's not just about the medic with the patient, there. As I say to supervisors: gentlemen, ladies, if you're doing all the talking, you're not doing all of the listening.

Kris Kaull

Yeah. I have this great quote from Sir William Osler, who said: “Always listen to your patient. They might be telling you the diagnosis.” And I know that that's really big and important to you as a podcast interviewer. You get a lot of insight by asking the question and then actively listening.

Rob Lawrence

Be the truth known, you're quite right because normally, when I interview somebody, I maybe have two questions, and that's it. Because your answer will lead me to my next question and take us in the direction you want to go to. And so it's not scripted, and it's not me talking over you, and it's not me trying to achieve the objective of getting my point across. It's me asking you to get your points out. And so that's my kind of hack, if you like, as well.

Kris Kaull

Yeah. For readers who are listening to this, you should look at your—it doesn’t matter which player you use—you should push the button right now and go back 10 or 15 seconds and listen to what Rob just said, and then go back 10 or 15 seconds to listen to it again. Because you ask a question intently, listen to the answers, and then you can ask the next question after that. It's not about going through SAMPLE OPQRST. It's about listening to what they say and then digging deeper in.

Rob Lawrence

It annoys me to watch a lot of these newscasters and news reporters these days who have an agenda and actually don't even let the speaker finish before they're either contradicting or correcting the answer that hasn't even been given yet. And that's not the way to conduct an interview, or indeed a patient history-taking encounter.

Kris Kaull

History-taking hack number seven is about situational awareness. And I know that you've seen this prior. You've seen the video—if not, we'll put it into the show notes.

There is a group of individuals all bouncing a basketball. There's a team that's wearing white shirts and a team that's wearing different colored shirts. And it says, how many times do they pass the basketball between those that are wearing the white shirt? And as you're intently focusing on the white shirts, you don't see that there's something happening in the background of the video, and you're like, wait, I missed that? And if you watch the video again, you’re like, how did I miss that?

And I won't do any spoilers on that—I will leave that video with you, Rob, to put into the show notes. Then I showed another video, and once again, it was about situational awareness—and no spoilers on that. Just watch the video, and then watch it again, and maybe again, and you'll continue to see more and more about situational awareness and understanding your surroundings.

Rob Lawrence

Great. Well, let's hack onto the next hack.

Kris Kaull

Yep. Hack number eight is: be kind. And I always just say that there's a difference between being nice and being kind. I say that being nice is when you don't want to embarrass your colleague or your friend or your partner, so you don't tell them they have spinach in their teeth. Being kind is telling them they have spinach in their teeth so they don't walk around all day with spinach in their teeth. Right?

It's about being there as an advocate for the patient. And during this time, that's why I said, when you say things like, “Why did you call 911?” you're already setting them up on the defense. You're already questioning who they are as a person instead of saying, “Man, this might be one of their worst days. So bad, in fact, that you reached out to us because you didn't have anybody else to call. How can I walk alongside you?” Be kind. 

History-taking hack number nine is: what your patient says may not be what they really mean. How many of us have asked questions, and you get to the hospital, and they answer, but somebody else asks it slightly differently? Or, they thought through it, and they say something. This is more of a visual example, but I showed a screenshot of a text where part of the middle of the text didn't go through. And so this buddy is texting this other buddy, and the guy says, “Hey, what's up?”

He’s like, “Dude, you're going to kill me. I was a little drunk last night when talking to your wife, and I ended up banging her … and your daughter.” Well, that's because the middle section of that text was missing. I mean, that sounds terrible, right? It sounds crass. But the truth is that the missing part of the text that was undelivered says, “Hey, what's up, dude? You're going to kill me. I was a little drunk last night, and I was talking to your wife, I ended up banging her car in the driveway when I pulled out. And I think I also hit your daughter's bike too. I’ll come by and fix it later. But please say sorry for me to your wife and your daughter.”

Listen to what your patient says and make sure you understand. We always think that they understand what we're saying, and we understand what they're saying. Not necessarily. 

I have my last one for you. History taking hack number ten is a list of do's and don'ts: 

• Don't ask leading questions. Ask open-ended questions. 
• Don't skip important discussion items. Instead, dig further into those. 
• Don't infer bias that creates the history. Instead, start listening to the history.
• Don't interrupt. Instead, listen and follow up with additional questions. 
• Don't assume the answer. Instead, ask more relevant questions about the associated symptoms.
• Don't be afraid of the quiet. Instead, just give them time to think about it and provide more detail. 
• Don't use medical lingo. Instead, use plain language. 
• Don't leave them confused, but do summarize what they told you. 
• Don't believe that all five questions—OPQRST—are all that you need. Instead, look at that as the starting place and ask if there's anything they would like to add.

Rob Lawrence

I'm going to throw one in as well. Don't start a question with the words, “Wouldn't you agree that…” because I either A) have to agree, or B) argue.

Kris Kaull

So as we close this up, let's take a look at that patient that we originally talked to—and imagine all the questions we could have asked that patient—and talked to about feeling weak and having this pressure on their chest. 

What brings you in today? Tell me how you're feeling. Are you currently in pain? How long have these symptoms been going on? Is there anything that makes these symptoms worse, or relieves them? Are you taking medications or supplements for this? What about: do you smoke, use alcohol, or other drugs? How often do you exercise? What exercise activities do you usually do? For how long? Describe a typical breakfast, lunch, or dinner. Right. We're looking at fatty intakes or salt intakes.

Have you had any heart surgeries in the past? What's your stress level right now? What’s your stress level over the previous year? How about your family history? Do you have anybody who's living with you or is living that has heart disease or any cardiovascular issues? What about family members who've had cardiovascular issues and died at an early age? How old were they? What happened to them? What's your typical day? Any safety concerns, such as extended driving or any fainting spells? Did you ever experience chest pain? Is this the same as what you had before? Explain this like catching your breath. What do you mean by that? Is there wheezing? Is there shortness? Do you have a history of respiratory problems, or is it just feeling weak?

Do you ever feel like you don't have the energy or feel lethargic or fatigued? That heart, when you said it's racing, does it feel different? Do you feel palpitations or anything like that? Do you have any swelling in your legs or feet? Is there anything else I should know?

Beyond the SAMPLE and OPQRST, I've just listed about 25 more questions you could have asked this one patient to get a better history and once again be a better advocate for your patient.

Rob Lawrence

So that's exactly where we go from the medic to the podcast, because the classic podcast-ending question is, Kris, is there anything I haven't asked, or anything you haven't told me?

Kris Kaull

Well, I think the thing that I would offer is that this isn't my presentation. This might be my presentation because I presented at the Big Sky EMS Symposium. But I want to share all these resources with everybody out there. I'll be providing you a link to this presentation as well as some of those show notes so that when people have this, they have access to the presentation. And my goal is if one person's a better historian and one patient has better care because of this, it's worth it.

Rob Lawrence

And our job will be done. So, Kris, thank you. Don't forget, you can follow us on Apple Podcasts, SoundCloud, Stitcher, Spotify, Podbean, and Amazon Music. And once again, if you're enjoying the show, please take a moment to rate and review us on the platform that you are listening on. Kris Kaull. Thank you very much. How can we get in touch with you?

Kris Kaull

That's great. It's Kris Kaull, with “k’s” —you can find me via a quick Google search, or on Twitter, LinkedIn, and Facebook. The truth is, I'm at a spot in my career where my job is to pay it forward and help walk alongside others as they're working through their journey in EMS, just like others have done for me before. So reach out. Reach out and give me feedback or anything else you'd like to add to this.

Rob Lawrence

I agree with you. Our job now is to find the new us. Uses—us plural. Sir, thank you so much. I really appreciate your time.

Kris Kaull

Rob, thanks for the invite.

Download Kris's presentation materials here. In case you missed it, check out part 1, in which Kris and Rob discuss the first five hacks for improving your history-taking! 

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