Patient Assessment
EMS
It takes some know-how to get the necessary information while putting the patient at ease.
Patient assessment in prehospital emergency care frequently takes place under the worst possible circumstances. Fire rescue personnel do much of their patient assessment in such difficult places as under overturned autos, in ditches, and in poorly lighted tenament hallways.
Because of the pressures of the emergency situation, probably no other subject will spark more intense and emotional debate. Instructors and authors on the subject want physical assessments and patient histories to include precise details, such as a five-minute auscultation for bowel sounds and information on the allergy to aspirin the patient had as a child 20 years ago. On the other hand, dispatchers and authorities such as the American College of Emergency Physicians would like us to minimize the time spent at the scene, especially in the case of a patient with severe trauma.
So—where do you draw the line in examining and questioning the patient, and how do you carry out the process effectively? Consider from the start that the patient’s comfort and trust will help determine how much data you’ll collect. “Bedside manner” counts.
Be sure to introduce yourself to the patient, find out the patient’s name, and use it. If you’re unable to get the name, use “Sir” or “Ma’am” when addressing the person—even if the patient is unconcious. You’d be surprised by what unconcious people hear and recall.
Photos by Keith D. Cullom
If the patient is short of breath, try to obtain the history from a family member so the patient can conserve breath. But take the time to explain the reason for the “third-party” questions so the patient doesn’t become apprehensive and think you no longer trust his recollection and mental capacity.
Use a “team approach,” with one member of the team taking a history and doing a primary and head-to-toe survey while another member of the team takes the vital signs, places the patient on a monitor, and does such tasks as searching the refrigerator for a “Vial of Life” and the medicine cabinet for the patient’s medications. That way, the patient doesn’t have to answer questions twice from two separate rescuers—which is espedally important if the patient is short of breath.
If you’re sure and confident with your questioning and examination skills, the patient will put trust in the rest of your skills also. That can mean a lot. If your patient is complaining of chest pain and you convey the image that something is terribly wrong, the patient will certainly sense that and make it a selffulfilling prophecy.
The way you move while around the patient and on the way to the hospital speaks in “body language” to the person. Just as you should never run on the fireground, you should never run while in the presence of a patient. And for someone with chest pain, one of the worst things you can do is to rush the patient down the hall, throw the person into the ambulance, and proceed toward the hospital with lights and siren working. Why? The excitement will make the person’s heart beat faster and require more oxygen, doing more damage to the already oxygen-starved heart muscle. Even most of us seasoned fire service personnel feel our hearts beat faster when we hear the siren and see the red lights. (Some of us salivate.) Think of what it will do to the patient—especially when she realizes she’s the reason for the dash to the hospital.
On the other hand, don’t dawdle. Studies indicate that the “10minute rule” is very important: Any time you’re on the scene with a severely injured person more than 10 minutes, the chances of the patient surviving decrease drastically. Some departments have their firefighters write a special report when the scene time exceeds 10 minutes with a trauma patient.
That doesn’t rule out advanced life support. Critics of ALS like to imply that time spent starting intravenous fluids delays the patient from reaching definitive care. But a study done recently by my own department indicated that the time on the scene in basic life support calls was only two minutes shorter than the time on the scene when an IV was started. (The study covered about 200 patients, 40 to 45 percent of whom received ALS care.) This shouldn’t be interpreted as meaning that we can start an IV in an average of two minutes. Instead it means that a member of the fire rescue team made the decision to initiate an IV early in the emergency and had the IV fluid, infusion set, and needle already laid out while a partner finished the patient history and physical exam.
Having an IV access for medications already established also means you can move the patient with a little more confidence.
But never overlook the basics. And never forget to do the basics first. It does no good to attach the patient to a cardiac monitor if he ! doesn’t have an open airway. Most of the patients who die as a result I of automobile accidents in this I country die because of an obstructed airway, the first item of the | emergency medical service’s list of ABCs: airway, breathing, and circulation.
Remember that your patient assessment starts with the primary survey, a search for life-threatening conditions, which should go in ABC order. The primary survey should also check for such lifethreatening conditions as flail chest and severe hemorrhage. The primary survey of a horizontal patient is remarkably similar to the steps we all learned in basic cardiopulmonary resuscitation, with some other steps—such as a quick glance for life-threatening hemorrhage—added on.
The secondary survey is also known as the head-to-toe survey. Yet I’m surprised by the number of fire and rescue personnel who start the head-to-toe survey someplace other than at the head. A scatter-gun approach to the secondary survey is sure to earn you embarrassment when you reach the hospital emergency room and the doctors there find things that you missed. But a systematic secondary survey will take you from the patient’s head to the toes and miss nothing important.
Remember the key words of patient assessment:
- Inspect—look at the patient;
- Auscultate—listen to the patient (through a stethoscope);
- Palpate—put your hands on the patient to check for pulse, pain, rigidity, guarding, and crepitus;
- Percuss—thump your patient’s skin with your forefinger while you listen, preferably with a stethoscope, to determine the location of anatomical structures.
Little things count. Remember to check each patient for bilateral grip strength and bilateral foot strength. Be sure to check for Babinski reflexes—the curling of toes when you stroke the bottom of the patient’s foot with something rigid such as a key or the tip of your scissors. Look at the patient. Is the person lying flat with no distress? If so, it’s likely that the lungs are clear of fluid, or the patient would exhibit orthopnea (distress in breathing while lying down.)
And, because you’re doing patient assessment under conditions that are less than ideal, don’t be afraid to double-check. If it’s noisy and you have trouble hearing the patient’s blood pressure, doublecheck it by measuring the blood pressure by palpation. If you can’t find a vein in which to start an IV easily, get the patient on the stretcher and let an arm hang down, dependent, to give you a better opportunity.
Last but not least, you have to present the information gathered in the process of patient assessment in written form on your EMS run report (it’s important to leave a copy at the hospital with the patient) and in verbal form on the radio to the emergency room. Your patient assessment will often be judged by the quality of both these reports.
In regard to the written report, two axioms hold: If you don’t write it down, you can’t prove you did it; and a sloppy or incomplete report indicates sloppy or incomplete patient care.
It has also been said that in EMS you must past several tests. A written test and a practical skills test are the first two. The third test is when you pick up the radio to give a patient report—because if your patient report isn’t complete and accurate, you won’t transmit the information the emergency room needs, and you won’t receive the orders you’ll need to give the best level of patient care. ■
Glossary
Advanced life support—Invasive emergency medical care, which might include the use of intravenous or other tubes or electroshock to the heart.
Auscultate—To listen to a patient through a stethoscope.
Babinski reflexes—The curling of a patient’s toes in response to the bottom of the foot being stroked with something rigid.
Basic life support—Noninvasive emergency medical care.
Crepitis—The sound that broken bone ends make when they grate together.
Dependent—(In reference to a
limb) Positioned below the level of the body.
Flail chest—The detachment of a segment of the rib cage caused by three or more ribs being broken in two or more places.
Guarding—Tensing up in reaction to a stimulus.
Orthopnea—Distress in breathing while lying down.
Palpate—To put one s hands on a patient to check for conditions and certain vital signs.
Percuss—To thump a patient’s skin with a forefinger while listening to determine the location of anatomical structures.
