Download - “BASICS” OF BASIC SCENE ASSESSMENT
“BASICS” OF BASIC SCENE ASSESSMENT
Amy Gutman MD ~ EMS Medical [email protected]
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 [email protected]