1. “BASICS” OF BASIC SCENE ASSESSMENT
Amy Gutman MD ~ EMS Medical Director

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

3. 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

4. NREMT EMT SKILL REQUIREMENTS
Assessment
Operational
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

5. 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

6. 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

7. MOTOR VEHICLE COLLISIONS
PDOF Patterns
Frontal
Lateral
Rear
Rotational
Rollover

8. PDOF?

9. FRONT END COLLISION INJURY PATTERN

10. PDOF?

11. “T BONE” PELVIC FRACTURE

12. PDOF?
Rollover

13. UNRESTRAINED PATIENT W/ ROLLOVER

14. 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 ?

15. WARNING SIGNS Fighting or loud voices Weapons used / visible
Signs of drug use
Unusual silence
Knowledge of prior violence
Panic
Remember your inner voice

16. 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

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

19. 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

20. 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

21. PROVIDERS’ ROLES Data collection Data analysis Data application
Rapid assessment
Data analysis
Differential diagnoses
Data application
Treatment plan

22. CLINICAL DECISION MAKING: GUTMAN’S PORNOGRAPHY PRINCIPLE

23. SICK

24. NOT SICK

25. SICK

26. NOT SICK

27. LIKELY TO BE SICK

28. 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

29. DATA?

30. 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

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

32. ASSESSMENT?

33. ASSESSMENT?

34. INITIAL ASSESSMENT: AVPU
Begins with 1st impression
Evaluate patient, environment, appearance & activity
If patient has AMS
Glucose
Narcan
Oxygen
Head Trauma / CVA
Cardiac

35. ABCDE PET PEEVES Missed respiratory distress Missed injuries
Fully dressed patients
Abnormal vitals with no explanation
Uncorrected symptomatic hypotension

36. DON’T MISS THE FATA INJURY

37. 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

38. WTF INJURIES?

39. 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

40. SUBTLE FOCAL INJURIES

41. 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

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

43. 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

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

45. DON’T MISS THE SECOND INJURY

47. ASSESSMENT: EXTREMITIES & NEURO
Injury / deformity
Pulses
Movement
Sensation
Instability
Neurological:
GCS / AVPU
Deficits
Time
Type

48. 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?

49. 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

50. 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

51. 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”!

52. Thanks For Your Attention! prehospitalmd@gmail.com