Patient assessment – Medical:
Scene safety: When approaching any scene, the priority is our own safety and that of other responders. Once we know the environment is safe, we need to determine the number of patients on scene, the additional resources we may need, and we need to apply proper PPE based upon call details.
Initial assessment: Sometimes called the “doorway assessment” is a first glance at the patient. This brief look at our patient allows us to form a general impression of the patient's condition. In the initial assessment we are looking specifically at 3 things:
-The patient's positioning/LOA. Are they awake?
-The patient's work of breathing
-The colour and condition of the patient's skin
This initial impression essentially allows us to decide if we think this patient is Sick (requiring rapid intervention) or Not Sick (we have some time with this patient).
Primary assessment: The primary assessment follows the ABCDE format. The purpose is to identify immediate threats to life, and correct them as they are encountered. YOU CANNOT MOVE ON WITH ASSESSMENT UNTIL THREATS HAVE BEEN CORRECTED.
A-Airway: Is the airway patent? Do you need to suction? Is an adjunct required?
B- Breathing: Is the patient breathing? If so, is the breathing adequate to sustain life? Do we need to intervene with supplemental O2 or PPV.
C- Circulation: Assess radial and carotid pulses, and observe skin condition, colour, and cap refill. Is there any obvious serious hemorrhage?
D- Disability: This is a quick neurological evaluation of the patient, to determine orientation to person, place, time, and situation. Additional assessments such as stroke evaluation can also be performed here.
E- Expose: Look for burns, trauma, urticaria, cyanosis, etc.
Once life threats have been identified and corrected in the primary assessment,, we need to determine if we are going to treat on scene (stay and play), or if we need to extricate and treat enroute to the ED (Load and go). Once transport decisions have been made we can move on to our secondary assessment.
Secondary assessment: While your partner takes vital signs, we can begin our secondary assessment by first identifying the patient's chief complaint (the reason why we were called). Based on the chief complaint we will develop a differential diagnosis that we will use our history and physical to narrow.
Once we have a chief complaint, we want to determine the history of presenting illness. This traditionally follows the format SAMPLE, and OPQRST may also be used for pain or dyspnea.
SAMPLE is more logical if re-arranged to SEPMAL (I cannot take credit for this. Check out the EMS 20/20 podcast for this pearl).
S- Signs and Symptoms: What are the symptoms the patient is experiencing? Has the patient experienced this before? Is the patient experiencing any symptoms in systems associated with the chief complaint?
E- Events prior: When did the symptoms start? Was it a gradual or a sudden onset? What was the patient doing when the symptoms began/leading up to the onset? Does anything improve the symptoms, and does anything make them worse?
P- Past medical history: What other medical conditions does the patient have? A good way to ask this if the patient is unsure is: “Do you have any problems with your heart, your lungs, any diabetes, any epilepsy, any history of stoke or cancer?” Additional questions may include those about surgeries.
M- Medications: Is the patient taking any medications? This includes prescription medications, OTC medications, supplements, alcohol, or street drugs.
A- Allergies: Does the patient have any allergies?
L- Last oral intake: When was the last time the patient ate or drank, and have they had any recent changes in diet or appetite?
With regard to complaints involving pain or dyspnea we can utilize OPQRST:
O- Onset: When did it start? Was it a sudden onset or a gradual one?
P- Provocation/palliation: Does anything make it worse/better?
Q- Describe the pain. In the case of dyspnea we want to ask “is it more difficult getting air in or out?”
R- Radiation: Is the pain localized or does it move to other areas?
S- 0-10 severity scale.
T- Time: Is it constant or does it come and go?
Once we have completed our secondary history we want to perform a focused physical assessment of the systems involved in the patient's chief complaint. When we combine history and physical data we will have the information required to form and narrow our differential diagnosis, and select a subsequent treatment protocol for this patient.
Ongoing assessment: Once we begin transport we need to continually reassess our patient to look for any critical changes or trends in our vitals. Stable patients should be reassessed at a minimum of every 15-30 minutes, and unstable patients should be reassessed every 5-10 minutes. Additionally, we need to reassess the patient any time they exhibit a significant change, or any time we perform a critical intervention.
Recognizing an unstable patient:
Common indicators of patient instability include:
-ALOC
-Chest pain
-Hypotension
-Poor perfusion
-Major trauma
-Significant MOI
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