Patient Assessment

When traveling to a scene it is important to consider scene safety. Consider road hazards, time of day, weather. Observe for issues such as uneven or unstable surfaces, water, mud, and ice on the ground. When working on a roadway wear high-visibility gear. You may encounter many environmental hazards, from sharp metal and glass, leaking fluids, biohazards such as blood and body fluids, chemical hazards, electrical hazards such as downed power lines, water hazards, fires, explosions, and the threat of physical violence. Do you see any weapons that the patient can access? Place yourself between them and the weapon. Request the assistance of law enforcement personnel if the scene presents the potential for violence. In some cases you will need to quickly retreat from the scene until law enforcement arrives.

Traumatic injuries are a result of physical forces applied to the outside body. If the patient falls from the ceiling and lands feet first, the patient’s MOI would direct attention to possible injury to the feet. But significant energy likely transferred to other body areas and may have caused further injury in the patient’s legs and pelvis or even their spine. Blunt trauma, the force of the injury occurs over a broad area and the skin is sometimes not broken; tissues and organs underneath the area of impact may be damaged. Penetrating trauma occurs when an object pierces the skin and creates an open wound that carries a higher potential for infection. When there is a medical problem you examine the nature of illness (NOI). You must do your best to determine the patient’s chief complaint, the most serious thing the patient is concerned about. Use clues around you, talk to the patient, family, bystanders, and see if there are people experiencing similar conditions to determine NOI.

When there are mass casualty events it’s important to determine the number of patients. You will be in groups with a group leader and the group leader reports to the incident command system. When triaging, the patients are ranked in order of severity; this is often done by the most experienced tech.

When forming a general impression you can often tell a lot if you start out saying something like this. You can tell level of consciousness and airway before even beginning the exam. State something like, my name is Francois. I am an EMT and I am here to help, if they respond. This gives you a good general impression of a few factors. Tells you if it is life-threatening or not. External bleeding should be addressed before continuing the assessment. In your primary assessment you will need to address only gross LOC. Focused on rapid identification of potentially life-threatening problems. Avoid standing over patient and refer to the patient by name.

When assessing alertness, responsiveness, and orientation you can use the AVPU scale.
A – Awake and alert – patient’s eyes are open and aware and responsive to you and the environment. The eyes visually track people and objects.
V – Responsive to verbal stimuli, responds in some meaningful way when spoken to – moaning, speaking, or moving.
P – Responsive to pain – doesn’t respond to questions but cries out in response to painful stimuli. There are appropriate and inappropriate methods of applying a painful stimulus. Generally a pinch to the lower jaw or top of shoulder, keep in mind spine injuries.
U – Unresponsive – the patient doesn’t respond to any type of stimulus AVP. If in doubt treat as if unresponsive.

Orientation is commonly person, place, time, and event. Person is able to remember his or her name, place or current location, time and tell you about the current year, month, and day, and tell you about the event. If they respond to all four they are conscious and alert. If they don’t respond they are considered to be in an altered mental status. If you determine that the patient has any of the indicators for spinal motion restriction ensure that the unresponsive patient’s cervical spine is manually stabilized by either you or another provider; a cervical collar should be applied after primary assessment. Note potential for distracting injury.

When assessment of airway: bleeding and hemorrhage should be addressed before following a sequence of circulation, airway, and breathing. Make sure the airway remains open. A conscious patient who cannot speak or cry most likely has a severe airway obstruction. If identified, stop the assessment process and work to clear the patient’s airway. May be positioning the patient so the air moves in and out, suctioning liquids from the airway, or removing an obvious foreign body from the patient’s mouth using the Heimlich maneuver. Use the jaw-thrust maneuver to open the airway by placing the fingers behind the angle of the jaw and bring the jaw forward. If not traumatic use the head tilt–chin lift maneuver – tilt the forehead back and lift the chin – not used if the patient suffered trauma. Tongue may have fallen back, address by placing an oral or nasal airway. Clear foreign objects even with manual techniques or suctioning. Once you’ve confirmed that the airway is clear, you can continue your assessment.

After assessment of the airway breathing should follow. Is the patient breathing on their own (spontaneous respirations)? Is it adequate? Are there enough breaths per minute? Is the patient oxygenated with saturation greater than 94%? Positive-pressure ventilations should be performed if not breathing or too slow or shallow. More than 28 breaths per minute or less than 8 breaths per minute, too shallow with little movement of the chest wall or too deep with significant rise and fall of the chest. Speech is another indicator, normal or few words per breath. Observe for presence of retractions, indentation above the clavicle and in the space between the ribs. Use of accessory muscles – neck muscles, the chest pectoralis major muscle, and the abdominal muscles. Nasal flaring and seesaw breathing. Tripod position – patient is sitting and leaning forward on outstretched arms with head and chin thrust slightly forward. Sniffing position patient sits upright with the head and chin thrust slightly forward and the patient appears to be sniffing. Labored breathing is characterized by the patient’s position, concentration on breathing, and the increased effort and depth of each breath. In infants and small children labored breathing for a sustained period will lead to exhaustion where the person no longer has the strength to breathe leading to cardiac arrest which was caused by respiratory arrest. Respiratory distress occurs when a person has difficulty breathing and the work of breathing is increased. Respiratory failure occurs when blood is inadequately oxygenated or ventilation is inadequate to meet the demands of the body.

Finally there is the testing of circulation. In patients older than one who are conscious use the pulse at the wrist (radial). In patients older than one who are unresponsive use the carotid artery. Never press on both sides. Make sure to not use your thumb or you can mistake your own pulse. If there is no pulse in an unresponsive patient use the AED. If has pulse but not breathing provide ventilations at rate of 10 to 12 for adults and 12 to 20 for child. Apparent absence of a pulse in a responsive patient is not caused by cardiac arrest and should not begin using CPR or an AED on a responsive patient. In children under the age of 1 use the brachial pulse by elevating the arm over the infant’s head. Poor peripheral circulation will cause the skin to appear pale, white, ashen, or gray with a waxy translucent appearance similar to a white candle. Cold or frozen skin may also appear this way. When blood is not properly saturated with oxygen it appears blue, called cyanosis. High blood pressure may cause the skin to be flushed and red. Skin is hot when there is fever, sunburn, hyperthermia. The skin is cold when in shock or suffering from hypothermia – deals with inadequate perfusion. With poor perfusion the body pulls blood away from the surface of the skin and diverts it to the core of the body. In the early stage of shock (hypoperfusion) skin will become moist. When bathed in sweat, such as after strenuous exercise or when the patient is in shock, skin is described as wet or diaphoretic. Capillary refill happens when you press on a fingernail and it goes white because of blood missing; the refill time should be about 2 seconds. Not always accurate indication of poor perfusion in adult patients.

Extreme bleeding should always be addressed first. What is the point of having oxygen if there is no blood circulating? Bleeding from a vein may be characterized by steady blood flow while bleeding from an artery is characterized by a spurting flow of blood. Most bleeding can be controlled in most cases with direct pressure after applying a sterile bandage over the wound; will control bleeding in most cases. When direct pressure is not quickly successful or whenever you encounter obvious arterial hemorrhage of an extremity apply a tourniquet.

When assessing for injury remember DCAP-BTLS.
D – Deformity – misshapen body part.
C – Contusion – bruising, a collection under the skin.
A – Abrasions – loss or damage to the surface of the skin from rubbing or scraping.
P – Punctures – a small penetration through the skin into the soft tissue.
B – Burns – redness, blisters, or white areas of skin.
T – Tenderness – pain when an area is palpated.
L – Lacerations – a deep cut in the skin.
S – Swelling – a raised or enlarged area of soft tissue on the surface of the body.

When considering transport high-priority patients should be transported immediately. Unresponsive, difficulty breathing, uncontrolled bleeding, altered LOC, severe chest pain, pale skin or other signs of poor perfusion, complicated childbirth, severe pain in any area of the body are some examples of high-priority patients. Remember the Golden Hour, 10 minutes initial assessment, intervention and packaging, 20 minutes for EMS to arrive and 30 minutes EMS transport and initial hospital stabilization. If it is an isolated injury, splinting the wound might help more.

It is important to gather as much information on the scene because this may not be possible once transport has been initiated. Be sure to document date of the incident, patient’s age, patient’s sex, patient’s race, past medical history, traumatic injuries, surgical procedures and medical problems, patient’s current health status, diet, medication, drug use, living environment and hazards, physician visits and family history. Use Mr. or Mrs. last name, open-ended questions like what is the matter. Try to get further information and see if there are any other associated complaints. Use eye contact to encourage the patient to continue speaking, and repeat statements back to show you understand the situation. Do not interrupt and be empathetic toward the patient’s situation. Keep an eye out for medical alert jewelry, talk to bystanders or other patient medical history documentation. In cases of physical abuse or domestic violence contact law enforcement and interview patient and partners separately. Do not forget to ask about sexual history. Examples include when was the last time you had your period or if you are using performance enhancers. Their privacy is protected and their honesty will improve the level of care you can provide. Information you receive will be kept in confidence. Remember OPQRST and SAMPLE.

OPQRST
O – Onset – what were you doing when the symptoms began?
P – Provocation/palliation – does anything make the symptoms better or worse? How are you most comfortable?
Q – Quality – what does the symptom feel like? Sharp, dull, crushing, tearing? Does it come in waves? Ask the patient to describe the symptom.
R – Region/radiation – where do you feel the symptom? Does it move anywhere?
S – Severity – on a scale of 0 to 10.
T – Timing – how long have you had the symptom? When did it start?

SAMPLE
S – Signs and symptoms – what signs and symptoms occurred at the onset of the incident?
A – Allergies – is the patient allergic to any medication, food, or other substance? What reactions did the patient have to any of them?
M – Medication – what medication is the patient prescribed? Dosage, how often does the patient take the medication? What prescription, over-the-counter, and herbal medications has the patient taken in the last 12 hours? Are there medications the patient has been prescribed but is not taking? Does the patient take recreational drugs?
P – Pertinent past medical history – does the patient have any history of medical, surgical, or trauma occurrences? Is there important family history that should be known?
L – Last oral intake – when and what did the patient last eat or drink?
E – Events leading up to the injury or illness.

During the secondary exam: observe the face, inspect the area around the eyes and eyelids, check pupil function, look behind the ears for Battle sign – bruising behind an ear over the mastoid process that may indicate a skull fracture, check the ears for drainage or blood, observe and palpate the head, palpate the zygomas and maxillae, check nose for blood and drainage, palpate the mandible, assess the mouth and nose, check breath odors, inspect the neck observe for jugular vein distention – which is visual bulging of the jugular veins in the neck that can be caused by fluid overload, pressure in the chest, cardiac tamponade, or tension pneumothorax, palpate the front and back of the neck, inspect the chest and observe breathing motion, gently palpate over the ribs, listen to anterior breath sounds, listen to posterior breath sounds, observe and then palpate the abdomen and pelvis, gently compress the pelvis from the sides, gently press the iliac crests, inspect the extremities, assess distal circulation and motor and sensory functions, log roll the patient and inspect the back for tenderness or deformities.