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Patient Assessment
 
Web www.EmergencyMedicalEd.com

Patient Assessment is, without a doubt, THE most important skill that you will learn during your experience as an EMT student.  Without "assessment" ability, the EMT will never 'know' when it's appropriate to apply a Kendrick's Extrication Device (KED,) or IF helping the patient self-administer an "EPI-pen" is indicated, or "how much" oxygen the patient "really" needs.  It IS the basis from which ALL other decisions will be made.

Actually the 'entire scope' of the "skill" goes well beyond the patient.  The properly "honed" skill will include an 'assessment' of the patient, that's true, but it will also include an 'assessment' of the environment (the scene,) as well as a 'pre-assessment' of the "call," so that, when you arrive at the scene, you will 'grab' the proper equipment (stretcher type, 'treatment' adjuncts, personal protective equipment, etc.)  to better prepare yourself to deal with the patient.

The "first step" in the entire process actually begins before your involvement, with a properly trained dispatcher.  The dispatcher, who takes the initial call for help, should 'collect' as much pertinent information as is available, so that the "dispatch" is a complete one.  Knowing "where" you are going, a familiarity with the "location," and an understanding of the "problem," are all 'pieces' of information that will help you make a proper "pre-assessment."  While responding to the scene, 'armed' with the information supplied by the dispatcher and associating that information with your available equipment, your knowledge of the area, and your 'ability' to deal with the upcoming anticipated problems, will better prepare you (mentally and emotionally) to deal with this patient.  That "preparation" will also serve to present an 'organized' group of rescuers to onlookers, family members, and the patient, when your ambulance arrives at the scene, adding to the degree of "professionalism" perceived by the 'public.'

Once at the scene, a proper "patient assessment" begins with an 'assessment' of that scene.  As a matter of fact, the entire process of "patient assessment" is one that starts out very "general" and as the process continues, the focus becomes more and more specific.

The process includes four basic "steps."

Scene Size-Up

As mentioned above, your 'evaluation' of the scene should begin during the dispatch process, assuming that the dispatch was 'complete.'  But any 'scene' is a dynamic entity, changing from minute to minute, and an "up-to-the-minute" evaluation of this scene will actually begin as you arrive.  When approaching the scene, park the ambulance a reasonable distance from the scene, but DO NOT enter the 'scene' with your emergency vehicle.  At most scenes, law enforcement personnel will, most likely, have arrived first, and should have already defined the 'borders' of this scene. 

The "steps" involved in this "scene size-up" include"

  • Body Substance Isolation (BSI)

  • Scene Safety

  • Mechanism of Injury

  • Number of Patients

  • Need for Additional Help

  • Consider In-Line Immobilization of the C-Spine

With no intent to insult your propriety, please consider the two words, spoken more often by the majority of Emergency Service Providers when arriving at the scene of any major incident...

"Oh Shit!"

We offer these words as a quote, understanding that they are NOT within the acceptable limits of conventional conversation.  They do, however, express the reaction that many who arrive at this scene initially formulate (whether spoken or unspoken.)  This "initial" reaction can lead to a sense that some immediate engagement in this scene is, not only appropriate, but expected by those already on the scene.  DO NOT GIVE IN TO THIS SENSE OF URGENCY.  As a matter of fact, your first action is NOT to run into this scene (as an Emergency Service Provider, you should not RUN anywhere,) but to stop.  Take a nice deep breath (be careful not to get 'run over' by the other providers running to the scene L,) and look around.  Those providers running to the scene are concentrating on the "problem" expressed in the scene.  They may be unaware of the 'cause' of the "problem," and under such circumstances are more likely to become part of the "problem."  They may very likely be experiencing a phenomenon called "Tunnel Vision," and the 'experience' can be deadly.  While "looking around" as suggested above, be aware of several things:

  • Any additional Emergency Services traffic approaching the scene

  • Any "civilian" pedestrian and/or vehicular traffic attracted by the scene

(Civilian 'traffic' will MOST LIKELy be experiencing "Tunnel Vision" and they are not looking 'for' you or 'at' you.  The probability of injury to you, as a result of their Tunnel Vision is VERY HIGH.)

  • Any environmental problems (heat, extreme cold, mud, ice, unstable ground, darkness, other conditions that limit your vision or ability to safely navigate the terrain, etc.)

  • The presence of any hazardous materials, or POSSIBLE presence of such materials (spilled gasoline, leaking gas, airborne powders, unmarked "containers" of unknown substances, etc.)

    [As an 'aside,' please be aware that the company charged with the 'responsibility' for moving the greatest amounts of hazardous materials over the public highways (in most of the world) is United Parcel Service (UPS.)  They accept and manage that responsibility very well, and although the number of vehicular accidents involving UPS trucks is not unusually high, the likelihood that a UPS truck is carrying some hazardous substance is information that should be noted at any such accident.]

     

  • Downed electrical lines

  • Broken glass

  • Jagged metal

  • The possible presence of "evidence," at any crime scene.

All of this "input" is intended to provide YOU with a 'platform' from which to make a decision:  "Do I enter the scene, or not?  And, if so, what Personal Protective Equipment (PPE) will I bring with me?"

If the scene is found to be 'unsafe,' DO NOT ENTER IT, unless you can render it 'safe,' or until it has been made 'safe' by others.

Personal Note:  I actually have two short "war stories" to relate regarding scene assessment:

  1. Shortly after arriving at the scene of "Man fell from horse, with personal injury," my partner and I were directed to a field, where the patient was lying, having been thrown from his horse.  While approaching the field, I noticed that it was surrounded by a barbed-wire fence, and remember wondering how we would "get around" the fence.  My partner ran up to one of the fence-posts, grabbed it, and 'vaulted' the fence.  My initial reaction was, "I can do that!"  Having completed the 'vault' successfully, my partner came down in a very muddy section of the field.  The mud "grabbed" his ankles.  Unable to move, and incapable of maintaining his balance, he ended up face-down in a pile of "cow flops."  His experience taught me, in those few seconds, that I didn't want to "do that."  He was un-hurt by the incident, but rendered 'unsuitable' to provide patient care at that scene.  I had to 'find' a new partner for that call.

  2. More recently, we were dispatched to the scene of a motor vehicle accident "with injuries."  After arriving, as an "Advanced Life Support (ALS)" unit, we determined that there was only one patient needing ALS attention.  The patient was in the backseat of one of the two cars involved and, although accessible, could not be moved until the "Basic Life Support (BLS)" patients had been properly extricated from the front seat of this two-door vehicle. There being enough room in the backseat for one additional person, my partner 'climbed' through the side-rear window to treat the patient.  Wanting to provide 'support' for my partner (having successfully 'accessed' the patient,) I approached the two from the rear of the vehicle (the back window having been "blown-out" by the force of the accident.)  I leaned into the back window, using the rear deck for support.  Asked my partner if there was anything that she needed.  "'Not just now," was her response.  Relieved that she had no "needs," I retreated to one of the BLS units, and spent the next 15 minutes, or so, "digging" the broken glass out of my arms.  Glass that WOULDN'T have been imbedded in my bare arms, had I been aware enough to notice that it was scattered all over the rear deck of the vehicle, before I leaned on that rear deck, or smart enough to put on appropriate PPE (turnout gear) before entering the scene.

There are actually six "steps" to a properly performed "Scene Size-Up,"  We've discussed the first two;  taking some type of "body substance isolation (BSI) precaution (PPE), and determining if the scene is safe.  As we continue with  "Patient Assessment," and this part of the assessment (Scene Size-Up,) our focus will become more and more specific, more and more "focused." 

Consider, if you will, that this 'scene' is a traffic accident, that you have taken the necessary BSI precaution, and that the scene is safe.  As you begin to allow your 'focus' to concentrate on the "problem," you notice that the vehicle has struck a tree and has sustained substantial front end damage.  This is the third step in a properly performed "Scene Size-Up."  ("Determine the Mechanism of Injury.")

Continuing to approach the vehicle, at some point you will be able to determine visually how many occupants are in the vehicle.  "Determining the Number of Patients" is the fourth step in this process.

Having first-hand knowledge of the "Mechanism" and the "Number of Patients" you can now adequately assess "The Need for Additional Help."  The fifth of six steps.

The final step in this 'section' of Patient Assessment is to consider "Manual In-Line Stabilization of the C-Spine."

Please notice that your "focus" has gone from "none" (a general "view" of the scene) all the way down to "focusing" on the patient's C-Spine.  You've done this in an orderly fashion, and collected as much information as possible, in an attempt to protect YOURSELF first, then your partner, then by-standers, and finally your patient.

By creating the mental picture of a traffic accident, our intent has been to demonstrate how "Patient Assessment" is a process of increasing "focus."  When trying to remember this part of the process (especially for testing purposes at the end of your course,) it may help to remember the 'accident scene' from above and the order in which you were able to collect information as you moved closer and closer to the damaged vehicle.  To recap, they are:

  1. BSI

  2. Scene Safety

  3. Mechanism of Injury

  4. Number of Patients

  5. Need for Additional Help

  6. Consider Manual In-Line Immobilization of the C-Spine

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Initial Assessment

An Initial Assessment is basically what you did to establish the need for CPR, but includes those 'skills' and those pieces of adjunctive equipment that separate the EMT from a First Aider.  It includes:

  • A General Impression of the Patient (In CPR...Hey! What's that guy doing, just laying on the ground.)

  • Determine Unresponsiveness or Level of Consciousness (In CPR...  Are You Okay?  Are You Okay?)

  • Determines Chief Complaint or Identifies Apparent Life Threats

  • Assess Airway and Breathing

  • Assess Circulation

  • Identifies a Priority Patient or Makes a Transport Decision

Let's return to our motor vehicle accident for just a minute.  The last step in the "Scene Size-Up" section was to consider C-Spine immobilization.  It was the first time in the whole process of Patient Assessment that the provider actually 'touched' the patient.  "Touching" a patient is an excellent way to establish a "General Impression" of the patient's condition.  This 'concept' makes a great "link" from the last step in "Scene Size-Up" to the first step in "Initial Assessment," and should help you remember the proper order (another 'trick' to help remember what to do next, when being tested.)  If, after you applied C-Spine immobilization, you identified yourself to the patient and asked, "Where does it hurt," and the patient appropriately described the location and nature of pain that your "initial impression" suggested that the patient should be experiencing, it would 'lead' you to the next two steps in the Initial Assessment; "Unresponsive/LOC," and "Chief Complaint/Life Threats (This patient is "responsive" and seems to be appropriately describing the expected "chief complaint.")  With an "Unresponsive" patient, the properly trained EMT will be able to further categorize the "level" of unresponsiveness by using the AVPU scale, as described in Module 1 on the "Vital Signs and History" page.  The next two steps are just the ABC's of CPR (with some other 'stuff' thrown in there/more on this later.)  And the final step in the section on "Initial Assessment" is to take all this "information," (including the 'additional' information that will be collected during the "modified ABC's) and decide if this patient needs to be transported to the hospital immediately and/or may require "rapid extrication."

So...what about the ABC's.  Well, as an EMT, you are going to check the airway and the breathing simultaneously.  In addition, it is at this point that the patient should be considered for some form of oxygen therapy (nasal cannula, or oxygen mask/depending on the patient's 'needs.')  The 'position' of the airway MUST include proper immobilization of the C-Spine as established at the end of the "Scene Size-Up" section and may include the use of an airway adjunct, and the "amount" of oxygen administered in almost ALL cases will be 15 LPM by "non-rebreather mask" for this victim of potential blunt trauma.  When checking for circulation (C of the ABC's) you will first locate and control any bleeding, palpate and evaluate a pulse (our suggestion is that you palpate/evaluate both a central and peripheral pulse, then compare them,) and evaluate the patient's skin for color (pale, cyanotic, flushed, normal,) temperature (cool, warm, hot, normal,) and condition (dry, moist, diaphoretic, normal.)

Now it's time to take all the information gathered during the Initial Assessment and decide it you are going to "stay and play" or "load for the road."

Let's review the steps of this segment of patient assessment.  They are:

  1. Initial Impression

  2. LOC

  3. Chief Complaint/Apparent life threats

  4. Airway and Breathing (including O2)

  5. Circulation (including Bleeding Control, Pulse Assessment, and Skin color, temperature and condition)

  6. Identifying a priority patient and/or making a transport decision

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Focused History and Physical Exam

Up to this point in the assessment process, the 'steps' have been the same for every patient.  However, we must now distinguish between "trauma" and "medical" patients.  And, appropriately, some of the foregoing 'steps' will have already helped you classify this patient. 

Trauma Patients

We are going to assume "all the worst," in explaining this section of the assessment process.  It is important that you understand the ENTIRE process, but also understand that in the real world, 'steps' in the process may exclude other 'steps.'  Said differently, if during the process you 'locate' the problem (or 'localize' the 'problem area' of the body) deal with the problem (or 'problem area.')

Another quick war story:  Before EMT-B, when we used to teach 'EMT-A,' we taught a very strict trauma assessment process.  It started at the head, and wasn't complete until the EMT-A reached the feet.  It was simple enough, but it didn't really serve the "medical" patient's needs.  Upon arrival at the scene of a patient complaining of severe sub-sternal chest pain, radiating into the left arm, with associated palor and shortness of breath, the EMT-A would begin by assessing  the patient's head and scalp, continuing on to the patient's face, neck, thorax, abdomen, etc.  Even over the patient's objection that "The Pain is HERE!!," the EMT-A (following the strict guidelines laid out by his/her recent training) would just continue with "patient assessment" as they had been taught.  Even when presented with an alert trauma patient, the EMT-A might very likely be 'alerted' to the actual problem by this verbal patient, but would be 'encouraged' by his/her training to complete the assessment regardless of the 'findings.'

Today, unlike previous methods, patient assessment has evolved into a 'dialogue,' where the 'findings' may dictate the next step.  The explanation is more involved, but the practice is much more realistic, and more "common sense-ical."

Nothing that we do later, will mean as much, IF we don't 'know' the patient's condition NOW.  (Re-read it, it's confusing, but UNDERSTAND it.)

One 'tool' that will help us "understand" the patient's present condition is a quick, accurate set of BASELINE VITAL SIGNS.  (Include in this "baseline:"  pulse, respirations, and blood pressure.)  During your exposure to this patient, one of the concepts that you will be employing is the 'trending' of vital signs.  If in the middle of the process, we were to inform you that the patient's blood pressure was "60 by palpation," would you be concerned?  The 'proper' answer lies in the 'trend.'  If this patient initially had a blood pressure of 110/60 (now 60/palpation) the answer would be YES.  If the patient was originally in cardiac arrest (blood pressure 0 / 0) then the consensus would be that the patient is getting 'better.'  This 'trend' in vital signs can only be accomplished if the rescuer has an accurate set of baseline vital signs.

While taking the baseline set of vitals, ask the patient, "What happened?"  Even if you think that this is an unresponsive patient, you might be surprised to find that all this activity has actually elevated the patient's level of consciousness (and besides, it's a good 'practice' to constantly communicate with your  patient.)  If you have a responsive patient, get a SAMPLE history as part of the baseline vital signs.  If the patient is still unresponsive, and there are bystanders and/or family members around, ask them, "What happened?"  Ask family members to help provide the necessary information regarding your SAMPLE history (during this SAMPLE, you may need to employ the help of a fellow rescuer, to help accurately record the SAMPLE as well as the pulse, respirations and blood pressure.)

Your 'initial assessment' of this patient has not only helped you categorize this patient, but may have also 'helped' you focus on the actual part of the patient's body that needs immediate attention.  This is somewhat 'bittersweet,' in-as-much-as the 'problem' may be corrected very quickly, or ANOTHER problem (equally as important) may go unnoticed.  As stated above, we are going to assume all "the worst," and the resulting assumption must be that something else 'needs to be found.'

To attempt to locate the 'hidden' problem, the EMT-B performs a "RAPID TRAUMA ASSESSMENT."  This is a very rapid assessment of the patient from head to toe (without the 'specifics' that we will be discussing  in the "DETAILED PHYSICAL EXAMINATION.)  Rapidly check the patient's HEAD for signs of trauma, look for pooling of blood around the head and neck, look at the eyes (if they are opened,) notice the patient's skin color.  Check the patient's neck,  re-check the carotid pulse, notice if the trachea is generally mid-line while checking the pulse.  Look "generally" at the patient's body, look for pooling of blood, signs of trauma (including holes in the skin, holes or tears in clothing, bruising of the skin,) take a little time to see if the chest is rising and falling with each breath.  Check the extremities, look for pooling of blood, abnormal angulations, hole, tears and bruises.

If this part of the trauma assessment has not produced any new areas of "need," assuming that any 'found' life threats have been, or are being, handled, continue on to the "DETAILED PHYSICAL EXAMINATION."

A DETAILED PHYSICAL EXAMINATION is something that is specific to unresponsive patients (whether Trauma or Medical) and further specific to those unresponsive patients for whom the EMT-B has not yet found the 'reason' for the unresponsiveness (either as a result of the RAPID TRAUMA ASSESSMENT, or from the SAMPLE history.)  It is a head-to-toe examination, and resembles the patient assessment method mentioned above, as taught to EMT-A's.  For patients who have been 'categorized' as trauma patients, this examination should be performed in a "secure environment" (usually the back of an ambulance, enroute to a Trauma Center,) with the patient "trauma naked."

Keep in mind that immobilization of the Cervical Spine MUST be maintained throughout this process, for patients of suspected trauma.

Also keep in mind that where an "aspect" of the patient has left and right 'components,' that only one side is checked at a time.  The reason for this is, that if the patient reacts to any painful stimuli, and right and left aspects were being checked at the same time, the EMT-B would be unable to identify if the source of the reaction was from the right or left side.

Start at the top of the head.  Palpate the scalp and superior aspect of the skull.  You are looking for cuts, lumps, depressions, 'soft' spots, and unstable segments of skull (or as we explain to our students:  "wet stuff, hard stuff, soft stuff, or squishy stuff.")  Inspect the posterior aspect of the scalp and skull, to the extent that C-spine immobilization will allow, for the same "stuff."  Inspect the lateral aspects of the skull.  Inspect the ears, looking for blood, or cerebral spinal fluid.  Inspect the anterior aspect of the head, including the forehead and general appearance of the face.  Inspect the eyes, looking for discoloration, irregular or unequal pupils. Using a light source, check for "pupil response."  Check the nose for irregular shape or discharge of any blood or fluid.  Check the mouth, opening it to check for abnormal odor.  Check the maxillae, and mandible for instability.

Check the neck.  Re-palpate the carotid pulse.  Record the findings.  Inspect the neck for Jugular Vein Distention (JVD,) Tracheal Deviation, and the presence of Stoma.

Check the chest.  Inspect the surface for blood, holes, bruises and unstable segments.  Palpate the anterior aspect of the chest checking each rib (careful to check only one side at a time,) and following each rib around to the posterior aspect as far as C-Spine immobilization will allow.  Check for symmetrical rise and fall of the chest with each respiration, by placing the heels of your hands on the lower border of the rib cage (your fingers extended toward the patient's neck,) while waiting for the next respiratory cycle.  Both of your hands should rise and fall with the chest, symmetrically.  Auscultate the lungs for breath sounds and record the findings.

Check the abdomen.  Inspect for blood, holes, evisceration.  Palpate for lumps or rigidity, checking one quadrant of the abdomen at a time.  Use your finger tips to "look" as deep into the abdomen as possible.  Use you finger tips to "look" for that lump (it may be as small as a golf ball, or as large as a soccer ball.)

Check the pelvis.  First one side then the other.  Palpate each hip checking for instability.  Inspect each half of the pelvis, looking for blood, holes and bruising.  Check the pelvis as a unit (for stability) by placing the heal of each hand on the hips, wrapping the fingers around the hip toward the buttocks, "grabbing" the superior iliac crest, and applying gently increasing, but firm pressure downward, then VERY GENTLY, without risking movement of the patient, attempt to 'rock' the pelvis by attempting to elevate the superior aspect of the pelvis, while attempting to depress the inferior aspect.

Check the lumbar spine.  Slide a gloved hand under the patient, into the arch formed by the lower back (the "small of the back") to the extend possible without moving the patient.  Withdraw the gloved hand and inspect the glove for 'new' blood. (If signs of bleeding are encountered during this part of the assessment, perform the "posterior" check at this point, as explained below.)

Check the perineum.  Inspect the genitalia for signs of injury.  (During testing it is suggested that this process be verbalized only,  DUH!)

Check the extremities.  Upper and lower, one at a time.  (In any order.)  Circumferentially 'wrap' your hands around the proximal aspect of the limb and palpate toward the distal aspect.  Look for blood as you do so.  Palpate for lumps, and obvious inconsistencies in bone structure.  At the distal structure (hand or foot) palpate for structural inconsistencies and palpate each of the phalanges for the same inconsistencies.  Ask the patient to squeeze your hand (for hand assessment,) or push against your hand (for foot assessment.)  Check pulses at the distal structure (Radial pulse for the hand,  Posterior Tibial or Dorsalis Pedis for the foot.)  Scrape your thumbnail along the palm of the hand, or the pad of the foot, to see if the patient is reacting to sensory input.

Check the posterior.  This is, under 'normal' circumstances the final part of the detailed physical exam.  An over-simplified preview of the process suggests that you will log-roll the patient and inspect the posterior aspect of the patient's body, inspecting and palpating for all of the same "wet stuff, hard stuff, soft stuff, or squishy stuff."  However, in order to maintain a professional image, and prepare for the next 'step' in the process, while moving the patient as little as possible, we need to prepare to "apply" a long spine-board to this patient, in conjunction with checking the posterior aspect of the body.

Be certain that sufficient help is available to safely log-roll the patient, while C-spine immobilization is maintained.  Have other members of the team retrieve and place a long spine-board adjacent to the patient on the side of the patient opposite to the "rolling/inspecting" team.  Through the coordinated effort of the "rolling team" (as learned in "Lifting and Moving,") roll the patient until the posterior surface can be properly assessed.  Once assessed, place the backboard and roll the patient (again, in a coordinated manner) back onto the backboard.  Secure the patient to the backboard and prepare for movement to a near-by ambulance.

Check vital sign trend.  Re-assess the vital signs.  This will be the first of several sets, that will establish the 'trend.'

During this entire process it is important to address life threatening conditions that are encountered.  At this point it is appropriate to deal with any 'secondary' injuries or conditions that were revealed by the assessment process.  In the course of dealing with 'life threats' it is not only possible, but very likely that your decision to transport this patient occurs very early on in the assessment of this patient.  Consequently, the major part of the detailed assessment of the patient MAY occur in the back of the ambulance while enroute to the Trauma Center.  At whatever point you decide that this patient needs to be moved to the ambulance, employ the help of other members of the team, execute a proper log roll, render the patient's posterior aspect visible (by cutting the clothing 'up the back,' so that an appropriate inspection and palpation of the back can be performed, apply the backboard, and leave the 'balance' of the patient's clothing to act as a drape until the patient is 'secure' in the back of the ambulance.  Remove the balance of the clothing, once in the ambulance and continue with the detailed examination.

Once the DETAILED PHYSICAL EXAMINATION is complete, re-assess by starting it over again, as part of the ON-GOING ASSESSMENT.

To review the "steps" in this section (for a trauma patient,) they are:

  1. Select appropriate assessment (focused or rapid)

  2. Obtains, or directs assistance to obtain, baseline vital signs

  3. Obtains SAMPLE history

DETAILED PHYSICAL EXAMINATION

  1. Assesses Head (including skull, scalp, ears, eyes, face, nose, and mouth)

  2. Assesses Neck (inspect and palpate, JVD, tracheal deviation, stoma)

  3. Assesses Chest (inspection, palpation, auscultation, and symetry)

  4. Assesses abdomen and pelvis (verbalize assessment of the genitalia for testing purposes)

  5. Assesses the extremities (inspection, palpation, and motor/sensory/circulatory function)

  6. Assesses posterior

  7. Management of secondary wounds

  8. Reassessment of vital signs.


Medical Patients

If your patient is an unresponsive medical patient, your first effort to reveal the 'cause' of this condition should be to interview the patient's family for pertinent medical history that might have lead to this condition.  In the absence of this 'resource,' you will have to rely on your ability to 'uncover' the reason through a rapid physical examination (followed by a detailed physical examination, as directed by the rapid exam,) as outlined above for the trauma patient, and including the interventions for the "medical problem sub-categories," as explained below.  At a Basic Life Support level there is little more that can be done.  Don't forget the "basics," and do everything possible to 'maintain' this patient's condition until Advanced Life Support personnel arrive.  If the patient's condition is deteriorating, consider meeting the ALS squad enroute to the hospital.

Let's assume that our medical patient is alert and oriented.

As with any patient, the process of a FOCUSED HISTORY AND PHYSICAL EXAM, begins with an accurate set of baseline vital signs.  And...,as with any patient..., the properly trained EMT-B should associate baseline vital signs with a SAMPLE history. To refresh your memory the SAMPLE history includes:  S - Signs and Symptoms; A - Allergies; M - Medications; P - Past history; L - Last oral intake; E - Events leading up to the present illness or injury.  It is these two "steps" that are the equivalent of the 'rapid assessment' for an unresponsive patient.  The goal during this phase of the medical patient assessment is to FOCUS on the problem.

It is during the first part of this 'interview,' that the process has become more involved.

When questioning a medical patient about signs and symptoms, there are eight different "medical problem sub-categories" that need to be memorized, and a list of appropriate questions associated with each category.  They include:

  1. Respiratory - Onset? Provokes? Quality? Radiates? Severity? Time? Interventions?

  2. Cardiac - Onset? Provokes? Quality? Radiates? Severity? Time? Interventions?

  3. Altered Mental Status - Description of episodes? Onset? Duration? Associated Symptoms? Evidence of Trauma? Interventions? Seizures? Fever?

  4. Allergic Reaction - History of allergies? What was patient exposed to? How was patient exposed? Effects? Progression? Intervention?

  5. Poisoning and Overdose - Substance? When did patient ingest/become exposed? How much did patient ingest? Over what time period? Interventions? Estimated weight?

  6. Environmental Emergencies - Source? Environment? Duration? Loss of consciousness? Effects (general and/or local)?

  7. Obstetrics - Is patient pregnant? How long? Pain and/or contractions? Bleeding or discharge? Need to push? Other children? Date last menstrual period?

  8. Behavioral - How does patient 'feel'? Is patient suicidal? Is patient a threat (self and/or others)? Is there a medical problem? Interventions?

It is this part of the "Medical Patient" assessment that seems to complicate the process for most new EMT's.  There is no alternative.  The importance of the foregoing is demonstrated later in the program by the devotion of a complete chapter to each of these (sub-catagory) emergencies.  It is not the intent of the EMT-B program to develop EMT's into Diagnosticians (you do not necessarily need to know how to interpret all of the information) but it is the intent of the program to develop a unit of properly trained Basic Life Support Providers that will seamlessly merge with the rest of the patient care team (pre-hospital and in-house) by training those individuals to start the process of appropriate information gathering, and thus simplifying and assuring the continuity of patient care; along with training those individuals in the proper procedures to follow for each emergency (from a Basic Life Support point-of-view) thus improving the patient's prognosis and enriching the patient's outcome.

The rest of the SAMPLE history is somewhat less complicated and more straight forward.

The entire process, as is the case with all assessments, is to narrow the area of FOCUS.  Consequently, the title of this section..."FOCUSED HISTORY..."  AND... "PHYSICAL EXAMINATION."

Once the 'Focused History' has revealed an area of concern, the EMT-B is expected to focus and deal with the problem, appropriately, through a NOW "focused" PHYSICAL EXAMINATION.

Following a focused history and physical examination (depending on the amount of time involved) it may be appropriate to take another set of vital signs to start the 'trending' process.

Appropriate intervention may include establishing medical control at this point, depending on standing orders and local protocol.  And it is always appropriate to consider transporting this patient to the closest medical facility equipped to handle this type of patient.  The point at which transporting THIS patient becomes a consideration would be the result of the findings from the focused examination.

Once the "focused" physical examination is completed, don't forget to complete the "detailed" physical examination, so you can be certain that nothing was missed.  Include another set of vital signs in this detailed physical examination.

To review the "steps" in this section (for a medical patient,) they are:

  1. Signs & Symptoms (Hx. of present illness, Respiratory, Cardiac, Altered Mental Status, Allergic Reaction, Poisoning/Overdose, Environmental Emergencies, Obstetrics, Behavioral)

  2. Allergies

  3. Medications

  4. Past pertinent history

  5. Last oral intake

  6. Event(s) leading to present illness (may include trauma, unless 'ruled out.'

  7. Focused physical examination (may include complete rapid assessment

  8. Vital signs (baseline, if not already done AND trending)

  9. Interventions (including medical direction and/or standing orders, and appropriate BLS "non-directed" intervention)

  10. Transport

  11. Complete the Detailed Physical Examination

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Ongoing Assessment

As the name implies, patient assessment is a never ending process.  When the EMT-B has 'discovered' the source of the problem, and has intervened to the extent that he/she is capable, AND there seems to be nothing left to do, it is time to start over.  Our interpretation of ONGOING ASSESSMENT, however, it that it is the process in reverse.

Re-assess the "problem" to which you were able to focus, first.  By so doing, you will know if the interventions that were 'applied' to the patient had any effect (positive or negative) AND will determine whether the interventions need to be continued adjusted, or abandoned.  Then 'un-focus' a little, and re-assess the entire patient (including a set of vital signs) to be certain that nothing was overlooked.

This is actually the FINAL ACT OF FOCUSING. It 'forces' you to focus your attention on the patient during the transport to the hospital.  There is NOTHING quite as embarrassing as arriving at the Emergency Department of the hospital (with a fully prepared team of in-house medical providers, ready to go) with a patient that has 'died' enroute.

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This completes the explanation of the patient assessment process.  But is really only the foundation upon which you will build the patient assessment skill.  The skill will develop over time and will include not only the memorized process, but personal experience with each type of patient.  Patients, like the 'dynamic scene' that you assessed at the beginning of this process, are dynamic as well.  No two patients will react to the same illness/injury in the same way.   It is impossible to teach the interpretation of this subjective reaction using an objective tool.  But, as a new student, you need a basis (foundation) from which to start.  We feel that this information, when committed to memory, provides the best foundation that the teaching community has to offer.  There are NO SHORTCUTS.  Memorize this process.  DO NOT assume that the assessment skill will develop over time without it.  Understand that 'medical' patients and 'trauma' patients are not assessed or treated in the same manner, but in several spots in the assessment process, the opportunity exists to re-classify the patient from one category to the other.  The assessment processes are distinct but they also interrelate.  It's a confusing concept, but one that you need to know is acknowledged by your instructors, as a source of confusing and frustration for you.  Never-the-less, the skill is so important to the development of a properly trained EMT-B that none of your instructors will accept anything less than perfection when evaluating your performance in this area.

HANG IN THERE.

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Last updated: 04/13/13.