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

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Presentation on theme: "“BASICS” OF BASIC SCENE ASSESSMENT Amy Gutman MD ~ EMS Medical Director"— Presentation transcript:

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 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 AssessmentOperational

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

17

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 – 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

21 PROVIDERS’ ROLES Data collection – 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

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 1 st 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

46

47 ASSESSMENT: EXTREMITIES & NEURO Extremities: – 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”! “F_ _king Get to the Hospital”!

52 Thanks For Your Attention!


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