Transcript Document
“BASICS” OF BASIC SCENE ASSESSMENT Amy Gutman MD ~ EMS Medical Director [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 Assessment • 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 Operational • 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 • 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 ? onto scene 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-ofcontrol” – 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 Attention! [email protected]