Amy Gutman MD ~ EMS Medical Director prehospitalmd@gmail.com

• Systematic method of scene
& patient assessment
• Look at cool photos…see how your eyes & gut lead to assessment & management strategies

• The majority of patients seen daily require competent performance of basic interventions
• Although it’s not “sexy”, the most basic AND most difficult skill is patient assessment

Assessment
• Scene size-up, initial assessment, reducE patient anxiety
• Focused history for trauma, medical, geriatric, pediatric & special population patients
• Detailed physical exams & ongoing assessment
• Communication & documentation
Operational
• Ambulance operations
• Infection control procedures
• Scene safety, access, extrication
& hazardous materials emergencies
• Multiple casualty incidents,
START triage & weapons of mass destruction

ASSESSMENT STARTS WITH
DISPATCH
• Emergency dispatch designed so crew receives information to appropriately manage the scene
– Trauma vs medical
– Life-threatening conditions
– Multiple patients / vehicles
– Special hazards (Fire, haz mat, water, weather, traffic)
– Requires special personnel or equipment
– Reported violence
– Pre-arrival instructions

• Scene safe?
– Police / Haz Mat required?
• Establish “Danger Zone”, Access
& Egress
• Medical, Trauma, Both?
– A family all with "flu“
– MVC with unconscious pt w/o obvious injury?
• MVC
– PDOF & speed of vehicles
– Restraints
– Position in Car
– Other injuries

• PDOF Patterns
– Frontal
– Lateral
– Rear
– Rotational
– Rollover

FRONT END COLLISION INJURY PATTERN

Rollover

UNRESTRAINED PATIENT W/ ROLLOVER

• Avoid urge to rush onto scene
• Tunnel vision may cause you to overlook safety precautions & require rescue yourself
• Ask Yourself:
– PPD?
– MOI? / Nature of illness?
– Number & type of patients ?
– Need for additional help ?
– Triage & Incident Command ?

• Fighting or loud voices
• Weapons used / visible
• Signs of drug use
• Unusual silence
• Knowledge of prior violence
• Panic
– Remember your inner voice

SCENE CONTROL
• Establish control immediately, access & egress
• Key is the confidence with which you interact with patient, family & prehospital personnel
• Work with police to establish control / preserve evidence
• Know when the scene is “out-ofcontrol”
– Too many confounders
– Too many patients

SPECIAL
CIRCUMSTANCES
• Recognize early to rapidly request additional resources
– Toxins
– Crash scenes
– Crime scenes
– MCI
– Water / Weather

MASS CASUALTY / DISASTERS
• Any event overwhelming available resources
• MCIs often trigger a health crisis
• Disasters often compounded by poor planning, disjointed communications costing time, resources, & lives

• Early recognition of personnel & equipment needs
– 1 st on scene calls “Code Black”
– Most experienced on scene is IC
• Triage maximizes outcomes by effective resource allocation & patient sorting
• Know local / regional resources for appropriate back-up

• Data collection
– Rapid assessment
• Data analysis
– Differential diagnoses
• Data application
– Treatment plan

CLINICAL DECISION MAKING:
GUTMAN’S PORNOGRAPHY PRINCIPLE

DATA COLLECTION: CRITICAL THINKING
• 911 call to transfer of care
• Constantly evolving
• “Unconsciously Conscious” thought process
– “Fundamental” knowledge
– Data organization
– Comparison to similar situations
– Construction of data-driven plan

• Use what you “see” & what you
“know”
• Differential Diagnoses:
– Absolutely “No”
– Possibly
– Absolutely “Yes”
• Decide what is going to kill patient first & start intervening
• You will never fix what you do not consider

WHEN DATA DOESN’T MAKE SENSE,
ASK A DIFFERENT QUESTION

ASSESSMENT?

• Begins with 1 st impression
• Evaluate patient, environment, appearance & activity
• If patient has AMS
– Glucose
– Narcan
– Oxygen
– Head Trauma / CVA
– Cardiac

• Missed respiratory distress
• Missed injuries
• Fully dressed patients
• Abnormal vitals with no explanation
• Uncorrected symptomatic hypotension

• Ideally obtained from patient
• Bystander “Rule of Indirect Uselessness”
– Runs of “Tachylawdys” & “Paroxysmal Sweet Jesuses”
• Assessments must be situational, systematic & performed the same way every time
– Signs & Symptoms
– Allergies
– Medications
– Pertinent PMH / PSH
– Last Meal
– Events leading to CC

• If the patient is conscious with a specific complaint, limit exam to that area
• If unresponsive or a vague complaint, assessment must be broader
– Onset
– Provocation
– Quality
– Radiation
– Severity
– Time

• If the patient is mentating, they are circulating
• ALS?
– Gut response
– Unresponsive or altered mental status
– Airway compromise or respiratory distress
– Inadequate perfusion / Shock
– Cardiac arrest / Chest Pain
– Uncontrolled bleeding
• Better to over-triage than under-triage

DETAILED PHYSICAL EXAMINATION
• Not Appropriate:
– Critical injuries
– Multiple Injuries
– Short transports
• Appropriate:
– Long Transports
– Prolonged Extrications
– Awaiting Aeromedical
Evacuation

• Scalp:
• Facial Bones:
• Ears:
• Eyes:
• Nose:
• Mouth:
• Neck:
Inspect & palpate
Palpate & evaluate for asymmetry
Drainage
Discoloration, foreign bodies,
Pupil size & reactivity
Drainage or bleeding
Loose / missing teeth, swollen / cut tongue,
Foreign bodies
JVD, trachea alignment

ASSESSMENT: THORAX & ABDOMEN
• Chest:
– Breath sound presence / quality, paradoxical motion, crepitus
• Abdomen:
– Firm / soft, masses, pulsations, tenderness
• Pelvis:
– Stability, crepitus

DON’T MISS THE SECOND INJURY

ASSESSMENT: EXTREMITIES & NEURO
• Extremities:
– Injury / deformity
– Pulses
– Movement
– Sensation
– Instability
• Neurological:
– GCS / AVPU
– Deficits
• Time
• Type

• Assessment is a continuous process throughout entire patient encounter
• Reassess every time you deliver or change an intervention
– Repeat & record vital signs
– Repeat focused exam prn
– O2 delivery adequate?
– Bleeding controlled?
– Splint too tight?

• Leave a copy for ED (yes…some of us read it)
• Complete, legible documentation keeps you out of trouble more than good patient care
– Never written, never done
• Errors occur
– When they do, document what happened & what steps were taken to correct it
– Never attempt to cover up errors
• Narrative must have pertinent positives & negatives

• I can’t figure out what happened
• Too much / not enough info
• Illegible anything
• Made-up acronyms
– “DMF”
– “TSTL”
• Concrete statements
– “Entry wound”
• Sloppy charting = sloppy care

SUMMARY: DON’T OVERLOOK THE OBVIOUS
• Is the scene safe?
• Is the patient sick?
• What does your gut say?
• Standard: A, B, C, D, E, but
Don’t forget the “F, G, H” ~
F
G
H

Thanks For Your Attention!
prehospitalmd@gmail.com