Fire EMS

Fire-Based EMS: Patient Assessment: The 360° View

Patient assessment is, without a doubt, our most important EMS skill. Without good assessment abilities, an Emergency Medial Technician (EMT) or Emergency Medial Responder (EMR) will never know when it’s appropriate to take action or change their direction in critical decision making. Good assessment is the basis from which all medical and trauma care decisions are made.

As we discussed earlier in Engine Company EMS, assessment of safety is critical. Scene safety is always of paramount importance. After ensuring safety, which is our first priority, move on to patient care, beginning with a general impression of the patient and his or her environment. Remember that the ground rule of constant safety awareness must be seared into your professional survival instinct to assure your longevity in this business. Assessment really begins prior to your arrival. Prearrival information assists with your safety and gives you the ability to use dispatch information to plan your course of action and initial treatment of your patient. It allows you to rapidly obtain the proper equipment, adjuncts, personal protective equipment (PPE), and proper use of personnel. Crew resource management allows every member of your engine company to be engaged appropriately in scene management and patient care.

  • Patient assessment starts with a very general approach and progresses to become more focused and specific. Initial assessment includes (but may not be limited to) these basic steps:
  • Scene size-up
  • General impression of the patient
  • Initial assessment
  • Focused history and physical exam (this may include a “rapid trauma assessment” or a “detailed physical exam,” depending on the outcome of the “Hx” and/or “PE”)
  • Ongoing assessment
Scene Size-Up
As mentioned above, your evaluation of the scene begins with dispatch information. At many scenes, law enforcement personnel will have arrived prior to fire or EMS companies. The “steps” involved in this scene size-up include:
  • Body substance isolation (BSI)
  • Mechanism of injury (MOI)
  • Scene safety
  • Mechanism of injury, with consideration of spinal immobilization
  • Number of patients
  • The need for additional resources
As the first arriving engine company, you and your crew may be overwhelmed with tasks, especially at multiple casualty incidents, cardiac arrests, or those with critical trauma patients. DO NOT GIVE IN TO THIS SENSE OF URGENCY. Never run into any scene, but instead, stop, take a deep breath, look around, assess the situation and determine what resources are needed. Then you can focus on patient needs and act definitively, treating your patient using the skills you learned in the classroom coupled with your experience. Sensory overload can lead both you and your crew to develop “tunnel vision.” Some elements for you to consider regarding the concept of situational awareness include:
  • Additional emergency services traffic approaching the scene
  • Civilians, pedestrians, or vehicular traffic attracted to the scene
  • Environmental elements that pose additional threats to the scene:
      • Extreme cold or heat
      • Mud
      • Ice
      • Unstable ground
      • Darkness or other conditions that limit your crews visual ability
      • Hazardous materials
      • Downed electrical lines
      • Broken glass
      • Jagged metal
      • The possibility that it is a crime scene
Initial Assessment
An initial assessment gives you a general idea of your patient’s status and includes elements such as:
  • Your initial general impression
  • Determining unresponsiveness or level of consciousness
  • Determining the chief complaint and identifying life threats
  • Assessing airway, breathing, and circulation
  • Identifying priority patients and assisting with critical decision making skills
 
Focused History and Physical Exam

Up to this point in the assessment process, the steps have been the same for every patient. After the initial assessment, we must distinguish between trauma and medical patients.

Trauma

Today, unlike previously, patient assessment has evolved into a dialogue with the patient, where the findings dictate the next steps. This practice is far more practical. Nothing we do later will mean as much if we don’t understand the patient’s condition early on. Using assessment techniques like baseline vital signs, SAMPLE history, and rapid trauma assessment all increase our insight.  

Baseline Vital Signs

  • Pulse
  • Respirations
  • Blood pressure
  • Skin temp and condition
This “baseline” gives you a beginning point to measure effects of your treatment and changes (improvement or decline) in the condition of your patient. While a set of baseline vital signs is taken, another crew member should obtain a SAMPLE History. This acronym considers the following:
 
 S- Signs and symptoms

 

A-    Allergies

M- Medications

 L- Last oral intake

 P- Past medical history

 E- Events leading up to the incident

This history can be obtained by questioning the patient. family, or a bystander.

 

RAPID TRAUMA ASSESSMENT

This is a very rapid assessment of the patient, moving from head to toe. Rapidly check the patient’s:

 

HEAD – Look for signs of trauma, like pooling of blood around the head and neck. Look at the eyes (if open), and notice the patient’s skin color.

NECK – Reassess carotid pulses, notice if the trachea is generally mid-line while checking the pulse. Look “generally” at the patient’s body for pooling of blood, signs of trauma (including holes in the skin, holes or tears in clothing, and bruising of the skin).

CHEST – Is it symmetrical, rising and falling with each breath? Do you notice crepitus upon palpation? Is there any subcutaneous emphysema present?

ABDOMEN – Check all four quadrants of the abdomen for painful areas, distention, and discoloration.

 

EXTREMITES – Check the extremities for wounds, bruises, blood, angulations, punctures, temperature.

An excellent acronym to use while performing your Rapid Trauma Assessment is DCAP-BTLS.
  • Deformity
  • Contusions
  • Abrasions
  • Punctures / penetrating Injury (Are they distinctly different?)
  • Burns/bruising
  • Tenderness
  • Lacerations
  • Swelling

The acronym should be used as a reminder to the engine company EMT or EMR of what types of traumatic injuries might be present during the physical exam. If your trauma assessment has not demonstrated any areas of need and exhibits no life threats, continue on to the “DETAILED PHYSICAL EXAMINATION.”

 DETAILED PHYSICAL EXAMINATION-

The detailed physical exam is more specific exam. It is a head-to-toe examination that closely resembles a rapid trauma assessment but lets the EMT or EMR slow down and look for other findings that may lead to changes in definitive care. A detailed exam also allows for better information in the hand-off report to the transporting ambulance crew (if your department does not provide EMS transport).

Start at the top of the head. Palpate the scalp and superior aspect of the skull. You are looking for cuts, contusions, depressions, deformities, and unstable segments of skull.

Inspect the posterior aspect of the scalp and skull, to the extent that C-spine precautions allow. 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, the face, nose, and orbits. Check the nose for irregular shape or discharge of any blood or fluid. Check the mouth, opening it to check for abnormal odor or foreign bodies. Check the maxillae, and mandible for instability. Maintain a patent airway at all times with appropriate adjuncts. Provide oxygen if indicated.

Inspect the eyes, looking for discoloration, irregular, or unequal pupils. Using a pen light, check for pupillary response. Are the pupils PERLA (Pupils Equal and Reactive to Light and Accommodation)?

  • Check the neck (use DCAP-BTLS.) Repalpate the carotid pulse. Inspect the neck for jugular vein distention (JVD), tracheal deviation, or the presence of tracheotomy.
  • Check the chest (use DCAP-BTLS.) Inspect the surface for blood; palpate the anterior aspect of the chest. Check for symmetrical rise and fall of the chest with each respiration. 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 (use DCAP-BTLS.)  Inspect for blood, bruising, and eviscerations. Palpate for masses or rigidity, checking one quadrant at a time.
  • Check the pelvis (use DCAP-BTLS.) First one side, then the other. Palpate each hip checking for instability. Check the pelvis as a unit with firm pressure (do not rock the pelvis back and forth) for stability by placing the heel of each hand on the hips, wrapping the fingers around the hip toward the buttocks. Grab the superior iliac crest, and apply gently increasing but firm pressure downward.
  • Check the extremities (again, use DCAP-BTLS.)  Wrap your hands around the proximal aspect of the limb and palpate toward the distal aspect. Look for blood as you do so. To check pulses, motor, and sensory (PMS), ask the patient to squeeze your hand or push against your hand. Check pulses at the distal anatomical structures (radial pulse in the hand, posterior tibial, or dorsalis pedis in the foot). Scrape your thumbnail along the palm of the hand or the pad of the foot to see if the patient is reacts to sensory input.
  • Check the posterior aspect of the patient using DCAP-BTLS  This is, under normal circumstances, the final part of the detailed physical exam. Be certain that sufficient help is available to safely log-roll your patient while maintaining cervical spine immobilization. Once assessed, place a backboard and position the patient on the board. Secure the patient to the backboard and prepare for movement to the ambulance.

At this point, it should be time for a crew member to re-assess the vital signs. During this entire process it is important to immediately address any life-threatening conditions that are encountered.

ON-GOING ASSESSMENT is a repetition of the detailed physical exam, looking for changes and trends to determine if the treatment you have provided is working.

On-Going Physical Exam Physical exam

  • Assess the head, including the skull, scalp, ears, eyes, face, nose, and mouth
  • Assess the neck by inspecting and palpate anterior and posterior sides and looking for JVD, tracheal deviation
  • Assess the chest: inspection, palpation, auscultation, and symmetry
  • Assess the abdomen and pelvis
  • Assess the extremities: inspection, palpation, and assessment of motor/sensory/circulatory functions
  • Assess the posterior
  • Manage of life threats
  • Reassess vital signs.
 

Medical Patients

If your patient is an unresponsive medical patient, your first effort to learn the cause should be to interview the family or bystanders for pertinent medical history or events that might have led to this condition. In the absence of any family or bystanders, you will have to rely on your ability to uncover causes through a rapid physical examination. There are a few ways to accomplish this. One is the SAMPLE History already mentioned. Another is utilizing the acronym OPQRST in conjunction with the SAMPLE History. This will also allow you to more effectively communicate with the ambulance, helicopter, or other Advanced Life Support (ALS) resource responding to your scene.

Let’s look at the acronym OPQRST and how you can use it to assess a patient and dictate treatment.
O- Onset: When did this start?
P- Provokes: Does anything make the condition better?
Q- Quality: What does it feel like? Ask the patient to describe it.
R- Radiates: Ask the patient if the pain or discomfort go anywhere else
S- Severity: On a scale to 1-10 (1 being the best, 10 the worst), how does the patient say he feels?
T- Time: Does the patient know exactly when it started? Has the pain been non-stop or does it come and go?

Focused Exam– From these assessment tools and your engine company experience, you can narrow down the problems affecting your patient and determine the care needed. These are some areas to concentrate on during the engine company assessment of your patient:

  • Respiratory – Onset, Provokes, Quality, Radiates, Severity, Time. What interventions has your engine company performed?
  • Cardiac – Onset, Provokes, Quality, Radiates, Severity, Time. What interventions has your engine company performed?
  • Altered Mental Status – Description of episodes, fever, evidence of trauma. Onset, Provokes, Quality, Radiates, Severity, Time. What interventions has your engine company performed?
  • Allergic Reaction – History of allergies, what was the patient exposed to? Onset, Provokes, Quality, Radiates, Severity, Time. What interventions has your engine company performed?
  • Poisoning and Overdose – Substance? When did the patient ingest it or how was he exposed? How much of the substance did he ingest, inhale, or get exposed to, and over what period of time? How much does the patient weight? Onset, Provokes, Quality, Radiates, Severity, Time. What interventions has your engine company performed?
  • Environmental Emergencies – Source? What environment were they in? Duration? What is their level of consciousness?
  • Obstetrics – Is the patient pregnant? How long (term)? Any pain, bleeding, or discharge? Does the patient need to push? How many times has the patient been pregnant and how many living children does she have? What is the date of her last menstrual period and was it normal?
  • Behavioral – Is the patient suicidal? Is patient a threat to himself or others? Are there any medical problems?

CONCLUSION

Your engine company actions set the tone and determine how efficiently and smoothly an EMS run progresses. Care of a patient is in your hands until additional help arrives and the outcome, including the patient’s survival, will certainly rest with how well your crew works together. There are few, if any, EMS calls where an engine company can stand around and await additional EMS resources without losing the confidence of the patient, family, and community in the ability of your fire department to handle emergencies. This assessment refresher will help you and your company to work safely and efficiently to provide high quality patient care. Engine companies are the first face of emergency services that patients see. First impressions not only determine the future of many patients, but the very future of the fire service.

J. Harold “Jim” Logan, BS, EMT-P/IC is a 27-year veteran of fire-based EMS and serves as a lieutenant firefighter/paramedic for the Memphis (TN) Fire Department. As an EMS administrator, he specializes in EMS consequence management, quality improvement, and education. He is a widely published author. Logan is an EMS instructor coordinator and fire instructor for the Memphis Fire Department and the state of Tennessee. He holds a bachelor’s degree in health and safety. For more than a decade, he has also served as a rescue/medical specialist and a medical coordinator for FEMA’s Tennessee Task Force One Urban Search and Rescue Team (TN-TF1).