Patient Assessment: Why the Basics Matter

Telepathy is possible in EMS, or so some think. Imagine standing in a house, watching a medic almost by magic assess a shortness-of-breath patient from the doorway without ever laying a finger on them. “Her CHF is acting up,” he tells you without checking lung sounds.

While the ability to rapidly determine a patient’s severity when first entering a room is important, this hands-off approach does not substitute for an actual assessment and does not constitute a diagnosis. The sad truth is that some of us have lost the ability to perform a basic hands-on assessment (if we ever really knew how) as those skills are replaced by technology like ECGs and pulse oximetry. These are important tools, but some providers have let them promote a culture of apathy and laziness. If diagnosis is really 90% of treatment, we’re in big trouble, and so are our patients.

The Importance of Assessment

Many of the recent improvements in EMS have focused on technology, but the fact remains that assessment cannot be replaced by gadgets. Assessment affects treatment by narrowing down diagnostic impressions and allows us to track treatment effectiveness. Assessment affects outcomes by ensuring that patients are transported to proper receiving facilities.

Studies have shown the importance of transporting directly to specialized receiving centers, a result of thorough assessment. Early recognition of stroke and rapid transport to appropriate facilities has been associated with improved treatment times.¹ Additionally, STEMI and trauma patients have shown improved outcomes when transported to specialized facilities.^2,3 Most prehospital personnel have stories where the destination meant the difference between a positive and negative outcome. A thorough assessment can be performed by practitioners at all levels of certification, and since destination decisions directly impact patient outcomes, prioritizing assessment is in the patient’s best interest.

Back to the Basics

The physical exam typically consists of inspection, palpation and listening. These steps progress from least to most invasive and proceed as the patient’s trust of the practitioner improves. Inspection helps the caregiver form a general impression of the patient’s status. The practitioner should be able to characterize the patient as stable, potentially unstable or unstable.⁴ This determination decides the urgency of the patient’s treatment. When forming a general impression, consider the patient’s:⁵

• Level of responsiveness (Are his eyes open? Does he track you visually?);
• Respiratory rate and quality (Is there chest movement? Is she breathing fast or slow? Deep or shallow?);
• Skin signs (color, presence of sweating);
• Positioning (Is she guarding or assuming a tripod position?);
• Level of distress (Does he have any discomfort or difficulty breathing?).

Inspection also determines the approach during the detailed exam. This step is important in trauma patients because it guides the physical assessment (for instance, gently palpating a limb with swelling to avoid patient discomfort).

Palpation represents the majority of the physical assessment. It can be performed with the fingertips or hand and involves light and deep pressure. During palpation, the practitioner determines structural stability but also assesses pulses, which are checked at the radial, brachial, carotid and femoral locations with fingertips using light pressure. In addition pulses at certain locations, regularity and strength are noted. An irregular heartbeat can indicate possible ECG changes. A bounding pulse can be found in fluid overload or sepsis, and weak pulses are found in hypotension. Palpation with the hand and varying pressure evaluates the patient for tenderness, inflammation and obvious deformity or instability. Findings of interest include:

• Edema (swelling caused by extracellular fluid that “pits” or indents when pressed);
• Guarding (protecting a painful area);
• Ascites (fluid in the abdomen).

When palpating an area with a known complaint, using light pressure first can protect the patient from unnecessary discomfort.

As an assessment technique, listening takes two forms: with a stethoscope (auscultation) and without. Listening without a stethoscope can reveal a blocked airway or obviously abnormal lung sounds. Since a blocked airway stops air from passing over the vocal cords, having the patient state their name can indicate whether their airway is open. A partially blocked airway can present as:

• Snoring respirations (caused by relaxation of the soft tissue in the upper airway);
• Stridor (high-pitched sounds caused by narrowing of the upper airway);
• Gurgling (caused by fluid or secretions in the airway).

Wheezing is sometimes heard without a stethoscope and indicates decreased airway diameter.⁵

Auscultation gives insight into the function of the heart, lungs and digestive tract. In the prehospital setting, auscultation is most common over the lung fields. Because of anatomical structures, lung sounds are best heard on the patient’s back and are checked in at least three positions on each side to assess each lung region. The process begins in the top position and proceeds left to right so bilateral sounds can be compared at each level. Potential findings include:

• Wheezes (whistling sounds caused by bronchoconstriction);
• Coarse crackles or rhonchi (rough “bubbling” associated with thick secretions);
• Fine crackles or rales (“bubbling” associated with fluid in the lungs).⁵

In patients with advanced airways placed, absent left lung sounds may correlate to a right main stem intubation. In general, abnormal findings during lung auscultation suggest a condition requiring treatment.

Auscultation takes practice. As becoming skilled at lung sounds takes time, learning to check bowel sounds is a gradual process. One learning method is to check bowel sounds and then ask an in-hospital practitioner to confirm your findings. Also, when a patient with an unusual disease process presents to the emergency department, take the time to assess that patient (with permission, of course).

Organizing an Assessment

The assessment itself is organized into primary and secondary phases. The primary phase consists of the mnemonic ABCDE—airway, breathing, circulation, disability and expose. Each step consists of assessment and any treatment indicated (like supplemental oxygen administration or positive-pressure ventilation). Depending on the severity and complaint, any of the assessment techniques may be applied. For example, assessment of breathing may include inspection and auscultation in an asthmatic patient but may include palpation while checking for a flail segment in a trauma patient.

The goal of the primary assessment is to create a general impression: whether the patient appears stable, potentially unstable or obviously unstable. Over time this ability to determine if a patient is “big sick” or “little sick” will serve a provider well. It should, however, be an adjunct to a hands-on assessment and not a substitute for it. The general impression of the patient should be revisited during the call and reevaluated in light of further findings.

The first step of the initial impression is determination of level of consciousness using the AVPU mnemonic. The patient is characterized as alert, responsive to verbal stimulus, responsive to painful stimulus or unresponsive. Next the airway is assessed for patency. For unresponsive patients the airway is manually opened. Respiratory status is then evaluated as the practitioner determines if the patient is breathing adequately, too fast (more than 24 breaths/minute), too slow (less than 8 breaths/minute) or not breathing at all.

Next, the patient’s circulation is assessed beginning with distal pulses (radial) and moving centrally (carotid) until pulses are found. The pulse is assessed for rate and quality, and the skin is checked for color and moisture. Pale skin or unexplained sweating can indicate a compromise of the circulatory system. Any major bleeding should be assessed and controlled at this point. Finally, other injuries that may increase the patient’s risk for disability are assessed and treated, with the patient being exposed to the extent necessary to perform the assessment.⁴ The rapid trauma assessment evaluates the “kill zone” from the patient’s head to the mid-thigh. Injuries needing immediate treatment include flail chest, sucking chest wound, major bleeding and evisceration. The primary assessment evaluates if the patient is emergent or nonemergent and provides a chance to treat life-threatening conditions.

In contrast, the secondary assessment is either a complete head-to-toe examination for the trauma patient or a focused physical examination for the medical patient. For trauma patients, the secondary exam uses the three physical exam techniques to assess the extent of injuries, allowing prioritization and treatment in order of severity. It is usually performed during transport to reduce possible delays in care. The secondary assessment for medical patients can often be limited to the body system or anatomical region affected by the chief complaint; however, an index of suspicion must be maintained for symptoms referred from elsewhere.

Since the secondary exam involves exposing, visualizing and touching the patient, perform it in a location that ensures privacy. The secondary examination begins by assessing the patient’s mental status and determining whether they are acting appropriately. Additional mental status evaluations assess language ability, mood, thought processes and memory. Any abnormal findings are compared to the patient’s baseline (if known from family or caregivers) and documented. The examination continues with a general survey including notations about the patient’s physical development, body structure, skin signs and any age-specific findings. Next the patient’s vital signs are checked, including respirations, pulse, blood pressure, oxygen saturation and capnography.⁴

The hands-on portion of the exam is divided by anatomical region or body system. This organization allows the practitioner to tailor the assessment to patient presentation. First the skin is assessed to ensure it is intact, with any wounds or discoloration noted, along with any discharge. The skin is checked for:

• Temperature;
• Color;
• The presence of moisture (diaphoresis);
• Turgor (ability to return after being pinched up, with poor turgor [tenting] indicating dehydration).

The remainder of the examination starts at the head and moves down. The head and neck are visually inspected and then palpated, noting any injuries or anatomic abnormalities. Next the provider assesses the patient’s eyes, determining visual acuity (presence or absence of blurred vision), the ability to track visually and reactivity of the pupils to light. The ears and nose are assessed for any discharge.

The provider then evaluates the chest and lungs. Respiratory rate and quality are evaluated again, and the chest is palpated, assessing for equal expansion and noting any deformity. Percussion evaluates the presence of a hemo- or pneumothorax, and lung sounds are auscultated. The practitioner may evaluate for jugular venous distention, indicating a possible tension pneumothorax (a late sign) or a chronic condition such as congestive heart failure.

The abdomen is then inspected, and bowel sounds are auscultated. The abdominal assessment requires care and practice in regards to palpation. The practitioner should proceed in a slow, logical manner to ensure nothing is missed. Palpation begins with light pressure and proceeds to deeper pressure. Possible findings include tenderness and masses, with those that pulse indicating a potential aneurysm. For certain patient presentations, assessment of the genitals is indicated, looking for traumatic injury, crowning in pregnant females, discharge or bleeding in either sex, and priapism (persistent erection) in males (a sign of potential trauma to the spinal cord).

Finally the patient’s extremities are assessed for deformity and trauma, range of motion and neurological status (sensation and motor function).⁴ Like all assessments, the organization of the primary and secondary examination requires practice to become skilled.

Specific Examinations

Two examinations used frequently in EMS that affect patient outcomes are the Cincinnati Prehospital Stroke Scale (CPSS) and the State of Maine exam. The CPSS is based on the National Institutes of Health (NIH) Stroke Scale, which assesses the severity of neurological deficits and guides the aggressiveness of treatment.⁶ When performed by a trained physician, the CPSS is highly sensitive and specific, results that can be reproduced by trained prehospital practitioners.⁶ It classifies three neurological findings as normal or abnormal.

The examination begins by asking the patient to smile or show their teeth. A normal finding is equal movement of both sides of the face; an abnormal finding is unequal movement. Next the patient closes their eyes and extends their arms, palms up, and holds the position for 10 seconds. A normal finding is both arms moving down together or not at all; an abnormal finding is one arm drifting relative to the other. Finally the patient repeats the phase “The sky is blue in Cincinnati.” A normal finding is the repetition of the phrase without slurring. An abnormal finding is slurring, speaking the wrong words or being unable to speak.⁷ Early recognition of stroke by EMS is associated with decreased treatment time and time from arrival at the hospital to first assessment.¹ 

EMS frequently evaluates minor trauma patients, many of whom have mechanisms of injury but no physical findings to indicate spinal injury. Beginning in 1994 (with an update in 2002), the Maine EMS system designed a study to evaluate the ability of paramedics to rule out the need for spinal immobilization. Of the 2,200 patients enrolled in the study, 919 (41%) were placed in spinal precautions. Of those, just 7 had significant spinal fractures. Among the 1,301 patients not immobilized, there were no spinal fractures noted.⁸ Since patients without spinal fractures are unlikely to benefit from immobilization (and may, in fact, be harmed by it), the ability to clear the spine in the field is an important one.

The State of Maine examination begins with a questionable mechanism of injury. The study used any force applied to the spine along its length, blunt trauma, motor vehicle collision, falls greater than three feet and any standing-height fall in adults as positive mechanism criteria. The practitioner evaluates the reliability of the patient and places unreliable patients in spinal immobilization. A patient is considered unreliable if he exhibits signs of intoxication or an altered level of consciousness or is unable or unwilling to participate.

Reliable patients are assessed for distracting injuries (those producing apparent pain that may distract from the presence of a spinal injury). Any patient with distracting injuries is placed in immobilization. Patients without distracting injuries are assessed to ensure they are neurologically intact. One method for testing neurological status is to ask the patient to spread and close their fingers against a constant force and flex and extend the wrist against force; test the ability to discern sharp and dull sensations in the upper extremities; and evaluate for numbness in the extremities. Patients exhibiting changes in neurological findings are placed in spinal immobilization. Finally, patients are evaluated for tenderness down the spine with direct palpation. Patients with no abnormal findings are deemed at low risk for spinal injury and can be left out of spinal immobilization.⁸

Though protocols vary between systems, the ability to rule out spinal precautions allows providers to immobilize only those patients who will benefit and can save patients who would not from unnecessary discomfort and potential harm. 

The Future of Assessment

As EMS grows as a profession, prehospital medicine will occupy a larger role in the continuum of patient care. In community paramedicine and mobile integrated healthcare programs, providers are moving out of the traditional roles of ambulance attendants and becoming increasingly involved in nonemergent care. With this responsibility comes the increased need for thorough assessment. If a provider responding alone to a residence or working in a clinic is presented with a nonemergent patient complaining of chest or abdominal pain, correctly diagnosing that patient depends heavily on taking a thorough history and performing a physical examination. When the ultimate question is not “Which hospital will the patient be transported to?” but “Will the patient be transported, referred or discharged?” the pressure on the practitioner increases.

Since the future of EMS may include new roles for EMTs and paramedics, a level of trust must be built between the prehospital and in-hospital communities. That will result, in part, from proving that EMS practitioners can perform a complete examination and correctly diagnose patients.

Conclusion

Ultimately the ability to assess a patient in a thorough and confident manner separates a skilled prehospital provider from an average one. By improving the assessment abilities of responders in an era of hospital specialization, patients benefit through timely transport to appropriate facilities. As EMS evolves, community paramedic programs may rely on single providers to treat and diagnose patients in out-of-hospital settings. Prehospital practitioners owe it to themselves, their systems, future providers and their patients to ensure the physical examination does not become a lost art.

To Learn More

For further information on the physical examination, consider taking an assessment-based course such as Advanced Medical Life Support (offered by the NAEMT) during your next recertification cycle. For an entertaining read about the importance of assessment in the diagnostic process, pick up Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis, by Lisa Sanders, MD. Sanders is a physician and columnist for New York Times Magazine and the technical adviser for the TV medical drama House.

References

1. Mosley I, Nicol M, Donnan G, et al. The impact of ambulance practice on acute stroke care. Stroke, 2007 Oct; 38(10): 2,765–70.

2. Vermeulen RP, Jaarsma T, Hanenburg FG, et al. Prehospital diagnosis in STEMI patients treated by primary PCI: the key to rapid reperfusion. Neth Heart J, 2008; 16(1): 5–9.

3. Demetriades D, Martin M, Salim A, et al. Relationship between American College of Surgeons trauma center designation and mortality in patients with severe trauma (injury severity score >15). J Am Coll Surg, 2006 Feb; 202(2): 212–5.

4. National Highway Traffic Safety Administration. National Emergency Medical Services Education Standards: Paramedic Instructional Guidelines. Department of Transportation, 2009, pp. 104–29.

5. Adam S, Odell M, Welch J. Rapid Assessment of the Acutely Ill Patient. West Sussex: Wiley-Blackwell, 2010.

6. Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. Cincinnati Prehospital Stroke Scale: reproducibility and validity. Ann Emerg Med, 1999 Apr; 33(4): 373–8.

7. Hurwitz AS, Brice JH, Overby BA, Evenson KR. Directed use of the Cincinnati Prehospital Stroke Scale by laypersons. Prehosp Emerg Care, 2005 Jul–Sep; 9(3): 292–6.

8. Burton JH, Harmon NR, Dunn MG, Bradshaw JR. EMS provider findings and interventions with a stateiwde EMS spine-assessment protocol. Prehosp Emerg Care, 2005 Jul–Sep; 9(3): 303–9.

9. Gu Y, Lim HJ, Moser MA. How useful are bowel sounds in assessing the abdomen? Dig Surg, 2010; 27(5): 422–6.

Patrick Lickiss is a paramedic and manager of clinical and education services with AMR in Grand Rapids, MI.