Transition Series: Topics for the EMT—Medical Assessment

Brady is pleased to share with you a preview of our forthcoming EMS Transition Series. Our first offering is for the EMT level. Transition Series: Topics for the EMT by Joseph Mistovich and Daniel Limmer provides both an overview of new information contained within the Education Standards at the EMT level and a source of continuing education for practicing EMTs. Intended for a new generation of EMTs, the text integrates new “topics” that were not contained in the U.S. DOT 1994 EMT-Basic National Standard Curriculum and existing “topics” at a much greater depth and breadth than what was contained in the typical EMT-Basic education program. This text covers what new EMTs need such as medical terminology, expanded pathophysiology and critical thinking. Educating and training EMTs using the new Education Standards, this text provides a solid foundation of knowledge to practice prehospital care.
During 2011, EMS World Magazine will feature exclusive excerpts from this new textbook. Visit www.bradybooks.com for more information and stay tuned for new topic previews throughout the year!

Standard: Patient Assessment

Competency: Applies scene information and patient assessment findings (scene size-up, primary and secondary assessment, patient history, reassessment) to guide emergency management

Transition Highlights

• Importance for the EMT to assess a medical patient with a body system approach, rather than with a complaint-based approach
• Comparison of the 1994 EMT-Basic curriculum and the National EMS Educational Standards regarding terminology used during the assessment of a medical patient
• Reinforcement of the critical thinking and differential diagnosis processes for the EMT while completing a medical assessment and developing a patient care plan
• Illustration of body systems the EMT should assess when confronted with a patient with one of several common complaints
• Important questions to ask the patient when assessing a certain body system given the patient’s complaint(s)

Introduction

Medical emergencies can be looked at as a mystery that must be solved. To solve the mystery, you will gather facts in your assessment.

The assessment of the medical patient is focused on the patient history. As mentioned in the article in the February issue, Assessment of the Trauma Patient, trauma patient assessment centers around the hands-on exam. The opposite is true here. You will gain a majority of your information about the medical patient from the history. This is not to say that the physical examination is unimportant, just that experience has demonstrated the importance of this history.

Again, as with trauma assessment, the EMS Education Standards have done away with a detailed, step-by-step process. Instead, you will perform examinations on body systems. For example, if a patient has chest pain or discomfort, you will assess the cardiac and respiratory systems. A patient with an altered mental status will require the examination of several systems to determine the potential cause and choose the correct interventions.

This is a dramatic departure from the old curriculum, which called for treating a patient simply based on the patient’s complaint without the level of clinical reasoning now required. During your class and subsequent field experience, you have likely picked up much of this knowledge.

Assessment of the Medical Patient

The processes used when assessing the medical patient are similar to the steps in trauma patient assessment (see Table I), but within each of the examinations are some differences.

Scene Size-Up

The scene size-up remains a foundational part of the assessment. You will ensure scene safety and determine what Standard Precautions are necessary. You will determine how many patients are present and what resources are necessary. There are rarely multiple medical patients (although it can happen), and the resources you need often center around lifting assistance for bariatric patients or advanced life support for critical patients.

You will also determine the nature of illness (NOI). This takes the place of mechanism of injury in the trauma patient. The NOI is your first impression of the kind of medical problem your patient has. You will determine this from a variety of sources. Dispatch will begin this process with the information it relays to you. You may also get information from family members or bystanders as you approach. Finally, as you approach the patient and arrive at his side, you will get this information and bridge into the primary assessment.

Primary Assessment

The primary assessment (Figure 1) begins with a general impression and then revolves around the ABCs—namely, identifying and correcting life threats.

The discussion that follows deals with a patient experiencing a medical emergency. If you encounter a patient who appears lifeless on first impression and does not appear to be breathing, you will begin the CAB sequence recommended by the American Heart Association. Remember that multiple rescuers may be present, so tasks may be handled simultaneously.

Beginning with the general impression, observe your patient as you approach (see Table II). This will be formative in how you continue the primary assessment. If you see an alert patient, your primary assessment will be much different than if you see an unresponsive patient on the floor.

There are other clues, though—and there are many types of patients between alert and unresponsive. You may observe patients who are clutching their chest, in the tripod position, profoundly anxious, or have such poor skin color you can see it from across the room. As an experienced EMT, you have likely seen some or all of these patients and realize that these are all important clues that, when observed and responded to properly, help to make your care more efficient and intuitive.

Airway

The patient’s airway must be open and clear of secretions (a patent airway) and remain that way. Responsive patients usually do this for themselves, whereas patients with an altered mental status may require a head-tilt, chin-lift to open the airway, and suction. Measure and insert an oral airway if the patient does not have a gag reflex. A nasal airway may also be an option if the patient will not accept the oral airway.

Unresponsive patients may require nearly continuous airway care throughout the call.

Breathing

Your patient must be breathing—and breathing adequately. You will carefully assess the patient to ensure adequate breathing. If the patient is breathing inadequately, you must provide positive pressure ventilation with a pocket face mask, bag-valve mask, or flow-restricted, oxygen-powered ventilation device (FROPVD).

Patients breathing adequately will receive oxygen based on their physical appearance, complaint, and pulse oximetry readings. In most systems, the days of giving all patients 12 to 15 liters via nonrebreather are over. Although you must follow your local protocols, many systems now recommend a nasal cannula, or even no oxygen, when patients have adequate signs of perfusion and normal pulse oximetry readings. It is believed that too much oxygen may actually cause harm to some patients (e.g., myocardial infarction [MI], stroke).

You should not, however, withhold oxygen from patients in significant respiratory distress or with signs of hypoxia.

Circulation

Circulation is the part of the primary assessment in which you continue to assess circulation (your general impression began this process). Assess the patient’s skin color, temperature, and condition as indicators of shock. Check the patient’s pulse. If the patient is unresponsive, quickly check the carotid pulse and evaluate for signs of life; if the patient is responsive, check the radial pulse. Note the general pulse rate (do not take the time to get an actual rate). Pay attention for abnormally fast or slow rates as indicators that the patient has a more serious condition. If the pulse is absent, begin the CPR with chest compressions and defibrillation sequence as prescribed by the American Heart Association.

The circulation portion of the primary assessment is also the place to look for bleeding. Although external bleeding is primarily a trauma issue, examine the scene in the early parts of the call for vomited blood, melena, or hematochezia, indicating gastrointestinal bleeding.

Priority Determination

The priority determination is the point at which you synthesize all the information you learned in the primary assessment and decide on a patient priority and status. A properly performed primary assessment will give you enough information to make this determination and will help you decide how quickly you should pace your call.

Secondary Assessment

The secondary assessment is where the major changes are found when assessing the medical patient. In addition to collecting a detailed history and vital signs, you will perform body system exams. These exams involve system-specific questions and a physical exam when appropriate.

Perhaps most significant is the fact that the EMT must understand enough about the specific complaint and possible causes to choose the correct body system exam or exams to perform. In medicine this is called a differential diagnostic approach. The clinician thinks of all the possible causes for a patient complaint (within reason), performs examinations to either rule in or tentatively rule out causes, and makes a treatment decision based on the findings. This is also referred to as going from possible to probable causes.

The way you perform a secondary exam will depend on a number of factors, the most important of which is the patient’s overall status. Patients who have an altered mental status, problems with the ABCs, any condition that could lead to instability (e.g., cardiac or respiratory difficulties), or any condition that requires prompt transport to appropriate facilities (e.g., patients with MI or stroke) will be expedited from the scene after a primary assessment and a quick history and physical exam (Figure 2) The remainder of the history and physical examination will be provided en route.

In stable patients—and those without critical complaints—you will take more time on the scene to do a complete history and examination.

History

When you took your initial EMT class, you believed the SAMPLE history was done in order and that there was a set of rote questions that could be asked of patients to get all the information you need. You now know that this is false. A history question that, when answered, brings up additional questions is better than a simple answer.

The history is a dynamic process—and arguably the most important for the medical patient (Figure 3). It is not the intent of this text to reteach the entire process and repeat simple mnemonics. Instead, this section will focus on insights that experienced providers use to make their history more effective and insightful.

Events: Because it is at the end of the SAMPLE mnemonic, many do not use this important concept to its fullest. Patients do not always know the things they should tell you. For example, with patients who suddenly passed out, it is important to know whether they were active or sitting. Patients may report that they were standing when they actually just went from a sitting to a standing position suddenly.

The patient’s activities and observations about the onset are also significant. Patients may recall specific feelings before an event (e.g., “whiting out” or an aura before a seizure). Carefully explore the events.

Onset: There is a significant difference in medical diagnosis between gradual and sudden onset. Using respiratory distress as an example, patients who have respiratory distress with a slow onset, pleuritic pain, and fever likely have a condition such as pneumonia. Patients who have a history of COPD often have a respiratory infection for a day or several days, which triggers an acute exacerbation. Patients who have a sudden onset are more likely to have an acute condition such as an asthma attack, aortic dissection, or an MI.

The classic presentation of a patient experiencing a worsening of congestive heart failure is a patient who calls because he suddenly cannot breathe. A careful history usually reveals weight gain, increasing orthopnea, dyspnea on exertion, and edema for days or even weeks before the call to EMS. (It is worth noting, though, that a rapid change in blood pressure can rapidly precipitate congestive heart failure or “flash pulmonary edema.”)

Medications: It is not enough to ask about medications or copy down the names from containers you find. Medications themselves often play a role in the patient’s condition, for a number of reasons. Patients often self-adjust their medication dose because of side effects or financial concerns. A recent change in medication, especially with antihypertensives and cardiac medications, can cause syncope or other medical problems. Remember to ask about over-the-counter medications.

Body System Exams

Even though body system exams (Table III) are new to the education standards, you already do some version of this in your current practice of EMS. The addition of pathophysiology to increase your understanding of the disease processes along with this new approach can help improve and sharpen your patient assessment.

The body system exams are a combination of the history and targeted physical examination (Table IV). Subsequent topics in this text will add to your knowledge about the pathophysiology and assessment of specific conditions.

Vital Signs

An initial set of vital signs followed by repeated sets for trending are important in the assessment of the medical patient. If you use noninvasive blood pressure or other mechanical devices, be sure to check vital signs manually at least once to verify the noninvasive readings, and more frequently if the patient is hypotensive.

Again, it is not the intent here to reteach basic skills, but the following insights into vital signs will help your assessment of the medical patient.

Watch vital signs for shock. Although EMTs primarily think of shock and trauma going together, medical patients can also experience shock. GI bleed, late sepsis, and MI are potential causes of medical shock.

Pay attention to the respiratory rate. EMTs tend to gravitate more toward pulse, blood pressure, and skin color. Respirations are a key vital sign and one of the earliest changes in shock—but respirations will also be an indication of acid-base balance. Patients with diabetic ketoacidosis and those who have overdosed on aspirin (acetylsalicylic acid) will have rapid, deep respirations in an attempt to rid the body of acids.

Check pupils. Pupils may be the only indicator of a narcotic overdose (although not every narcotic causes pinpoint pupils) and may also help alert you to intracranial bleeds that occur spontaneously (as opposed to those from trauma).

Trends are best. Always take and evaluate multiple sets of vital signs.

Reassessment

As with trauma, reassessment is performed about every 15 minutes for stable patients and about every 5 minutes for unstable patients (unless other priorities prevent it) (Figure 4).

The components of the reassessment include the following:

• Repeating the primary assessment
• Repeating vital signs
• Reassessing the chief complaint
• Reassessing the effect of interventions performed and ensuring that ongoing interventions are working properly.

Joseph J. Mistovich, MEd, NREMT-P, is chair of the Department of Health Professions and a professor at Youngstown State University in Youngstown, OH. He has more than 25 years of experience as an educator in emergency medical services. He is an author or coauthor of numerous EMS books and journal articles and is a frequent presenter at national and state EMS conferences.

Daniel Limmer, AS, EMT-P, has been involved in EMS for 31 years. He is active as a paramedic with Kennebunk Fire-Rescue in Kennebunk, ME. A passionate educator, Dan teaches basic, advanced, and continuing education EMS courses throughout Maine.

Howard A. Werman, MD, FACEP, is professor of Emergency Medicine at The Ohio State University. He is a teacher of medical students in the College of Medicine and the residency training program in Emergency Medicine at The Ohio State University Medical Center. He has been active in medical direction of several EMS agencies and is medical director of MedFlight of Ohio, a critical care transport service that offers fixed-wing, helicopter and mobile ICU services.