By Mick Messoline
The past 10 years have seen changes in the initial patient assessment. What was once called the primary and secondary assessment are now known as the initial assessment and detailed exam, respectively. No matter how they are labeled, there is one thing that has not changed: Fail to complete a quality exam, and you'll forever miss details vital to a positive patient outcome. Many publishers have joined pursuit of the perfect assessment. Books like "The 60 Second EMT," "Sick, Not Sick," and "The Street Medic's Handbook" are just a few that have coined different assessment approaches.* Acronyms have become very popular: OPQRST, DCAP-BTLS, and the original ABC's. Although it does not matter which of these tools you use, it does matter that you do the same thing every time.
During the initial assessment of any patient, it is vital to obtain details like the chief complaint, onset, duration, radiation, and provocation. This information is gathered very early in the assessment and referred back to throughout the patient contact. As a nontransporting medic, there are other details that can prove equally important. Medications, scene conditions, mechanism, and initial vital signs are key assessment components that a transporting medic may not have access to. As the first-arriving provider, special care should be taken to gather scene-specific information and document it. This documentation should then be passed along to the transporting medic to eliminate gaps in care.
Initial vital signs have changed significantly for the prehospital provider in the past 20 years. The foundation of blood pressure, heart rate, and respirations has been greatly expanded. Now included in baseline vital signs are things like oxygen saturation, blood glucose determination, temperature, and ETCO2 determination. These have all become relatively noninvasive assessment tools that provide rapid and accurate information. A good definition of an assessment tool is "anything that can be accomplished while still questioning a patient." If patient interviewing needs to stop, then the action should be considered an intervention and not an assessment tool.
Base line vital signs should be taken within the first few minutes of your assessment. Avoid the trendy inclination to obtain an initial "palpated" blood pressure. This is a prehospital tendency, and it is unacceptable in other acute care settings. The initial blood pressure should be auscultated or determined using an automated device. Though systolic blood pressure is often considered the golden standard, it is important to remember that the heart is perfused during diastole. A minimum Mean Arterial Pressure (MAP) of 60 is required to perfuse the coronary arteries, and MAP is impossible to determine without measuring a diastolic blood pressure. Though there are many devices more accurate for determining pulse rate, the act of palpating a pulse provides far more information than just a rate. It also allows the provider to determine skin signs and breaks the physical-contact barrier in a noninvasive and nonintrusive manner. For a regular pulse, a good rule is 15-30 seconds of palpation. Irregular pulses should be palpated for the entire 60 seconds. Respirations are best counted for 30-60 seconds to get an accurate impression of both rate and regularity.
Following the tactile portion of baseline vital signs, you can begin to assess values using electronic monitoring devices. Blood glucose is normally between 70-110 mg/dl. Any variation should be noted (addressing BGL issues will be discussed next month). Pulse oximetry can vary depending on multiple factors. Normal SpO2 ranges from 95-100 percent. ETCO2 (end tidal capnography) is a measure of cellular metabolism. The normal range is from 35-45. Any value below 30 or above 50 is a significant finding and should be noted. There are also several ETCO2 wave form alterations that may lead a provider to a differential diagnosis. It is very important to remember that all electronic monitoring devices have potential shortcomings. Use them to confirm information found during the tactile exam.
ECG monitoring is commonly used during the initial assessment. Many providers will use the ECG monitor to determine pulse rate. Although this is a great measure of heart rate, it is not a measure of systemic perfusion. An ECG can only provide the number of electrical impulses conducted through the heart each minute. It may show a rhythm that produces no pulse like PEA (pulseless electrical activity) or ectopic beats that do not perfuse. Keeping hands on a patient during your assessment is the quickest way to determine true circulatory efficiency.
The initial assessment performed by the first-arriving company sets the tone for the entire incident. Properly gathering and organizing information will assist in the transfer of care to the transporting medic. It is important to remember that much of the information available to the engine medic on scene may not be available to the transporting medic after leaving the scene. For this reason, it is important to document findings during the initial exam and pass that information along to the transporting crew. Developing a comprehensive and repeatable assessment is a necessity for the engine company medic. Following the same basic steps during each patient encounter minimizes lapses in treatment and loss of information during the transfer of care.
* The referenced books are used as examples only and are not intended to be a recommendation or critique.
Mick Messoline has been in the fire service since 1985. A paramedic and an educator, he has worked for the Denver (CO) Paramedics, Sacramento (CA) Fire Department, and Sacramento State University. He is a firefighter in Thornton, Colorado.
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