“BASICS” OF BASIC SCENE ASSESSMENT

Amy Gutman MD ~ EMS Medical Directorprehospitalmd@gmail.com

OBJECTIVES

• Systematic method of scene & patient assessment

• Look at cool photos…see how your eyes & gut lead to assessment & management strategies

BACK TO BASICS

• 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

NREMT EMT SKILL REQUIREMENTS

• 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

• Ambulance operations

• Infection control procedures

• Scene safety, access, extrication & hazardous materials emergencies

• Multiple casualty incidents, START triage & weapons of mass destruction

Assessment Operational

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

SIZING UP THE SCENE

• 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

MOTOR VEHICLE COLLISIONS

• PDOF Patterns

– Frontal

– Lateral

– Rear

– Rotational

– Rollover

PDOF?

FRONT END COLLISION INJURY PATTERN

PDOF?

“T BONE” PELVIC FRACTURE

PDOF?

Rollover

UNRESTRAINED PATIENT W/ ROLLOVER

TUNNEL VISION

• 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 ?

WARNING SIGNS

• 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-of-control”– 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

MCIs

• Early recognition of personnel & equipment needs – 1st 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

PROVIDERS’ ROLES

• Data collection– Rapid assessment

• Data analysis – Differential diagnoses

• Data application– Treatment plan

CLINICAL DECISION MAKING: GUTMAN’S PORNOGRAPHY PRINCIPLE

SICK

NOT SICK

SICK

NOT SICK

LIKELY TO BE SICK

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

DATA?

DATA ANALYSIS

• 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?

ASSESSMENT?

INITIAL ASSESSMENT: AVPU

• Begins with 1st impression

• Evaluate patient, environment, appearance & activity

• If patient has AMS– Glucose– Narcan– Oxygen– Head Trauma / CVA– Cardiac

ABCDE PET PEEVES

• Missed respiratory distress

• Missed injuries

• Fully dressed patients

• Abnormal vitals with no explanation

• Uncorrected symptomatic hypotension

DON’T MISS THE FATA INJURY

HPI: SAMPLE

• 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

WTF INJURIES?

HPI: OPQRST

• 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

SUBTLE FOCAL INJURIES

BLS vs ALS

• 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

ASSESSMENT: HEENT

• Scalp: Inspect & palpate

• Facial Bones: Palpate & evaluate for asymmetry

• Ears: Drainage

• Eyes: Discoloration, foreign bodies, Pupil size & reactivity

• Nose: Drainage or bleeding

• Mouth: Loose / missing teeth, swollen / cut tongue, Foreign bodies

• Neck: 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

SERIAL ASSESSMENTS

• 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?

PCR DOCUMENTATION

• 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

DOCUMENTATION PET PEEVES

• 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_ _king Get to the Hospital”!

Thanks For Your Attention!prehospitalmd@gmail.com