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

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 Data analysis Data application 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 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