Introduction to the ED Medical Screening Exam

By David Jaslow

Educating EMS providers about the actual process of firefighter medical evaluation is part of the difficulty of teaching rehab operations. This column and future articles will explain the medical screening exam (MSE) and discuss how and why they're conducted.

Rehabilitation is actually the end result of a process through which firefighters undergo a focused and directed medical evaluation. This is followed by measures designed to ease the load of heat stress, provide hydration and alimentation and return them to a state of homeostasis prior to returning to duty. Unfortunately, the directed medical evaluation is often neglected because it is not well understood and there is a paucity of material available in fire and EMS literature to describe this entity and why it is necessary.

The term "medical screening exam"refers to an evaluation reasonably calculated to identify emergency medical conditions suggested by presenting signs and symptoms. This is a different concept than triage, which is a French word meaning "to sort." Triage implies that victims or patients are voluntarily presenting themselves for medical evaluation when there is reasonable suspicion to believe that they are ill.

The medical screening exam is typically employed to determine whether the patient is acutely ill when there is not necessarily evidence to this effect. In the fireground setting, the purpose of instituting a medical screening exam is to determine whether or not the firefighter is acutely ill versus physically exhausted, since the presenting vital signs and physical exam findings may be the same. This concept will be expounded upon in Part II of this series.

Active labor
Federal law mandates that a medical screening exam be performed for every patient who presents to an ED which contracts with Medicare, essentially all public and private hospitals. Additionally, a medical screening exam must be performed on any patient who could be in active labor (to ensure that the patient will not deliver either in the hallway on the way to Labor and Delivery or during transfer to a facility which has obstetrics capability), and all patients who require transfer to another medical facility for any reason.

In this case, the MSE is performed to ensure that the patient is stable for transfer. If not, this information must be presented to the patient or who ever is legally authorized to make decisions on their behalf prior to the signature authorizing the transfer. Finally, any patient who is declined treatment in the ED has the legal right to a medical screening exam prior to being told "we are not seeing you or providing care for this complaint" (which is legal but rarely happens).

The medical screening exam must include, if indicated, diagnostic tests and specialty consultations normally available in the ED. Why would this be necessary? If an individual presents with a sudden onset severe headache, the standard of care is that at least a CT scan of the head is performed to rule out subarachnoid hemorrhage.

The medical screening exam to rule out such a condition cannot be completed without that study. Therefore, it is arguably malpractice to turn away a patient at the point of triage who presents with such a complaint without at least a physical exam and this test. In other circumstances in which the emergency physician is unable to exclude a disease or unstable condition without assistance from a consultant, this individual may have to be contacted for advice on patient disposition.

Sufficient information
The triage process alone is not considered to be an adequate medical screening exam. Why? Triage is not a process that is designed to detect an exact disease state. Rather, the point of triage is to collect sufficient information to determine how rapidly a patient requires emergency medical treatment and what level of care may be indicated based upon a chief complaint and basic physiologic markers (vitals).

Who performs the MSE? In the nation's foremost academic medical centers, it is always the physician. Nurses or other mid-level providers are not prohibited from performing a medical screening exam but they will be held to the standard of what a physician would have done. Thus, no patient is screened out of an ED without being seen by a physician or having a strictly defined algorithm applied, which has been defined by a physician.

The parallel to draw to fireground operations involves who staffs the rehab sector and evaluates the firefighters. Should this be an individual with the least training (First Responder or EMT-Basic) or should this be someone with the most training (EMT-Paramedic)? Are there other options such as having someone with the most training supervise others with lesser levels of training? This will be discussed in depth in future columns.

There is no exact definition of what constitutes a medical screening exam. The ED physician will order whatever testing is necessary to rule out an emergency condition. In some situations, the medical screening exam may become the complete patient work-up. In other words, there are circumstances in which it is impossible to exclude an unstable or emergent medical condition using only a brief evaluation. What is clear is that a quick look at the patient is insufficient to make this determination, i.e. the "you look OK" line doesn't cut it.

A typical MSE includes vital signs, level of consciousness, history of present illness and focused physical exam at a minimum. Diagnostic testing is driven by what is suspected on the history and physical and may include blood work, point-of-care testing, EKG, X-ray or CT, etc. There is a host of diagnostic testing available on the fireground which, will be presented in later parts of this series.

David Jaslow, MD, MPH, FAAEM is a board certified emergency physician who is fellowship trained in EMS and disaster medicine. He is the director of the Division of EMS and Disaster Medicine within the Department of Emergency Medicine at Albert Einstein Medical Center in Philadelphia. Dr. Jaslow is a state-certified Firefighter I and he is credentialed by the Pennsylvania Department of Health as a pre-hospital physician. He functions as a chief officer in several suburban Philadelphia fire and EMS agencies and provides medical oversight as the lead physician for the Bucks County Technical Rescue Task Force as well as Pa. Task Force-1 Urban Search and Rescue.