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.

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:

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:

Initial Assessment

An initial assessment gives you a general idea of your patient’s status and includes elements such as:

 

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

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.

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)?

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

 

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.

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.