WILDERNESS FIRST AID Patient Assessment Brent McKelvey, EMT-I Establishing Patient Rapport • Patients will form an opinion of you within the first few minutes, if not seconds of meeting you. – This includes how you… • Act • Dress • Talk • Establishing good patient rapport is essential to obtaining a good patient history and assessment. Introducing Yourself • “Hi, my name is ______. I’m trained in wilderness first aid and I’m here to help you today. Can I help? What seems to be the problem?” This also gives you permission to help the patient. • Eye contact, eye level • Be aware of body language Asking Questions • Use the patient’s name when possible. • Open-Ended Questions: – Where do you hurt? – Can you describe your pain? – What medical conditions do you have? • Closed-Ended Questions: – When did you pain start? – Is your pain sharp and shooting, or is it a dull and aching pain? – Are you cold? First Aid Report Form • Every space needs to be filled. • If it is not documented, it was not done. • It is important to document because you can easily forget things in an urgent situation. Scene Size-Up • Body Substance Isolation (BSI) Gloves, Eye Protection… • Scene Safety #1=You #2=Other Responders #3=Your Patient #4=Any Bystanders • Number and Location of Patients • Mechanism of Injury / Nature of Illness • Consider S-Spine Initial Assessment (1 of 2) • Overall general impression can give you a lot of information about a scene. • AVPU – Alert • Patient is able to answer questions appropriately. Patient should be able to answer questions about person, place, time and event. – Verbal • Patient responds to verbal stimulus. – Painful • Patient responds to painful stimulus only such as pinching the earlobe or pinching the skin above the shoulder. – Unresponsive • Self Explanatory Initial Assessment (2 of 2) • Airway – Head-Tilt, Chin-Lift or Jaw-Thrust if suspected head, neck or back injury. – Ensure a clear airway. Be aware of the tongue and any vomit. • Breathing – Look, Listen and Feel • Circulation – Radial or Carotid Pulse SAMPLE History • • • • • • Signs and Symptoms Allergies Medications Pertinent past history Last oral intake Events leading up to the accident Signs and Symptoms • Signs are conditions you can see, such as a bruise or laceration. • Symptoms are what the patient feels and tells you about, as in “My head hurts.” Allergies • Allergies to medicine. – Morphine, “sulfa” drugs, the “caine” drugs… ex: lidocaine • Allergies to natural products. – Wheat, eggs, pollen… • NKDA – No Known Diagnosed Allergies Medications • Try to obtain all the patient’s medications. This includes prescriptions, over the counter drugs, narcotics and street drugs. • A complete list of drugs can help you figure out what medical conditions a patient has. Ex: Lantus is insulin used for the maintenance of diabetes. Pertinent Past History • A patient's medical history is a valuable tool in identifying or diagnosing a medical condition. • A medical condition could be the cause of a traumatic problem. Ex: A patient had a seizure and falls into a creek. Last Oral Intake • When was the last time the patient had anything to eat or drink. • This can be especially useful with diabetic patients showing signs of altered mental status that have not had anything to eat in a while. Events Leading Up To The Accident • What was happening the moment before the accident happened. • Having a clear history of symptom onset or how an injury occurred helps in identifying possible life-threatening conditions. OPQRST • Onset- What was happening when your pain/problem began? • Provocation- Does anything make your pain better or worse? • Quality- How would you describe your pain? • Region/Radiation- Where is your pain and does it radiate anywhere? • Severity- Can you rate your pain on a scale from 1-10? • Time- When did the problem begin? Physical Exam • DOTS – Depressions – Obvious Deformity – Tenderness – Swelling • DCAP-BTLS – Deformities - Burns – Contusions - Tenderness OR – Abrasions - Lacerations – Penetrations - Swelling • Inspection, Auscultation, Palpation… -Or• Look, Listen and Feel… • Medical Tags. General Principles of the Physical Exam • • • • • • • • Do no further harm. Be complete and systematic. Use direct observations. Compare body parts. One person does the exam. Make multiple observations. Record all your findings. Do entire exam first and then go back and render first aid unless it is an urgent patient. • Do not move patient unless there is a safety issue. Head Start at the top of the head. Palpate the scalp and top of the skull. You are looking for cuts, lumps, depressions, 'soft' spots, and unstable segments of skull. Inspect the back of the scalp and skull, to the extent that C-spine immobilization will allow. Inspect the ears, looking for blood, or cerebral spinal fluid. Inspect the eyes, looking for discoloration, irregular or unequal pupils. Using a light source, check for "pupil response." Check the nose for irregular shape or discharge of any blood or fluid. Neck Check the neck. Re-palpate the carotid pulse. Record the findings. Inspect the neck for bleeding, bruising, or the presence of a stoma. Chest Check the chest. Inspect the surface for blood, holes, bruises and unstable segments. Check for symmetrical rise and fall of the chest with each respiration, by placing the heels of your hands on the lower border of the rib cage. Both of your hands should rise and fall with the chest, symmetrically. Abdomen Check the abdomen. Inspect for blood, and evisceration. Palpate for lumps, rigidity and guarding, checking one quadrant of the abdomen at a time. Pelvis Check the pelvis. First one side then the other. Palpate each hip checking for instability. Inspect each half of the pelvis, looking for blood or bruising. Check the pelvis as a unit for stability by placing your hands on either side of the pelvis and pushing up and down gently. Look, listen and feel for crepitus (grinding of two bones together.) Extremities Check the extremities, upper and lower, one at a time. Wrap your hands around the limb and palpate away from the body. Look for blood as you do so. Palpate for lumps, and obvious inconsistencies in bone structure. Ask the patient to squeeze your hand with theirs or push against your hand with their foot. Check pulses on the hand and foot. Cover the hand or foot and squeeze the finger or toe to test for sensory function. Back Check the spine. Slide a gloved hand under the patient, palpating the spine for any spinal abnormalities. Withdraw the gloved hand and inspect the glove for blood. Vital Signs • Check every 5 minutes on a severely injured patient or every 15 minutes on a non-severely injured patient. • Pulse • Breathing • Blood Pressure (not part of this class) • Skin Condition • Pupils Pulse • Normally 60-100 • Take note of rate, rhythm, and quality… – Rate: Numerical Value – Rhythm: Regular or Irregular – Quality: Strong or Bounding, Weak or Thready • Palpate pulses using two fingers and not your thumb. • Pulse sites include: The radial pulse in the wrist, brachial pulse in arm, carotid artery in the neck, femoral pulse in the thigh, dorsalis pedis in the foot, and the tibialis posterior in the ankle. Breathing • Normally 12-20 • Take note of rate, rhythm, and quality… – Rate: Numerical Value – Rhythm: Regular or Irregular – Quality: Deep or Shallow • Note any sounds associated with breathing: ex: gurgling, wheezing… Blood Pressure • Normally 120/80 • Systolic/Diastolic • A systolic pressure of 100 is needed in most patients to perfuse vital organs. Skin Condition • Normally pink, warm, and dry. • Take note of skin color, temperature, and condition. – Color: Pink tint, Ashen, Pale or Bluish – Temperature: Warm or Cool – Condition: Damp, dry, clammy… Pupils • Normally equal, round and reactive to light. (PERRL) • They should not be different sizes or sluggish to respond to light. • To test pupils, shade eye with cupped hand then expose to light. Dilated Pupils Constricted Pupils START Triage Background • Simple Triage And Rapid Treatment • Developed by Hoag Hospital and the Newport Beach Fire Department. • The whole process should take less than 60 seconds per patient. • The concept of triage is simply a method of quickly identifying victims who have immediately life-threatening injuries AND who have the best chance of surviving so that when additional rescuers arrive on scene, they are directed first to those patients. • If you are the initial START rescuer, you DO NOT stop to do other than the most basic intervention. If you attempt to treat every patient before completing the triage, you cannot assess the rest of the patients and identify the top priorities. Start Triage Three things to look at: “RPM” •Respirations •Over 30? •Pulse •Radial Pulse Present? •Mental Status •Follow Simple Commands? • GREEN – “Walking Wounded” or Minor • YELLOW – Delayed Care • RED – Immediate Care • BLACK – Deceased Example START Triage Scenario www.citmt.org START Triage Flow Chart www.citmt.org Example #1 • • • • • Can walk- No Respirations- 22 Respirations after repositioning- N/A Radial Pulse- Yes Can follow simple commands- Yes Delayed Example #2 • • • • • Can walk- No Respirations- 0 Respirations after repositioning- 36 Radial Pulse- Yes Can follow simple commands- Yes Immediate Example #3 • • • • • Can walk- Yes Respirations- 24 Respirations after repositioning- N/A Radial Pulse- Yes Can follow simple commands- Yes Minor Example #4 • • • • • Can walk- No Respirations- 0 Respirations after repositioning- 0 Radial Pulse- Can’t Find Can follow simple commands- No Deceased Example #5 • • • • • Can walk- No Respirations- 14 Respirations after repositioning- N/A Radial Pulse- No Can follow simple commands- Yes Immediate Example #6 • • • • • Can walk- No Respirations- 24 Respirations after repositioning- N/A Radial Pulse- Yes Can follow simple commands- No Immediate Putting It All Together • Use everything gathered from your patient history and assessment to base your patient treatment on. • By taking a through patient assessment you will be able to identify all patient injuries. • Remember to document all your findings on the first-aid report form. • Do no further harm.