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Upon arrival and first encounter, your training and experience is the best tool to use when sorting out immediate threats amidst a lot of commotion. There's a lot going on, so you can be at your best when your initial assessment follows a system:
- Scene assessment (including BSI).
- Assessment (S.A.M.P.L.E., P.Q.R.S.T., D.C.A.P.-B.T.L.S.)
- General Impression (unspoken: “Sick or not sick?” and “Serious injury or non-life threatening?”).
Assessment factors include:
- scene safety (to you, your partner, your team, your patient, and any bystanders)--your first priority, ALWAYS;
- environmental considerations,
- chief complaint (primary reason for EMS response, verbal or non-verbal, differentiating actual from misleading),
- recognition of life-threatening conditions,
- acknowledgment of non-life threatening conditions,
- putting into perspective distracting injuries,
Distracting injuries are injuries which, because of their associated sensational nature, may prevent a focus on the spine for identifying or ruling out spinal injuries.
♦ Regardless of the dramatic nature of other injuries (open fractures, burns, etc.), any spine tenderness warrants treatment as if there were spinal injury.
- focused vs. tunnel vision,
- patient cooperation, and
- EMT attitude (biases and labeling).
Major components of the patient assessment include
- standard body substance (BSI) precautions,
- scene size-up,
- general impression,
- initial assessment,
- SAMPLE history and OPQRST,
- baseline vital signs, and
- secondary assessment.
The primary component of the overall assessment of the medical patient is acquiring a thorough history. Acquiring a thorough and accurate history requires a balance of knowledge and skill, and helps to ensure the proper care will be provided for the patient.
Body substance isolation (BSI) and scene size-up (including scene safety) are paramount and dynamic for every response situation. The bare minimum requirement for BSI is a pair of clean gloves for every patient contact and can require more specialized equipment based on the situation.
Scene size-up includes projectile or impaling points of entry and exit, possible hazards, mechanism of injury or nature of illness, number of patients, additional resources needed, and C-spine consideration.
Scene size-up can be remembered via the mnemonic, "B-SMAC":
- Scene Safety
- Mechanism of Injury
- Additional Units Needed?
- C-spine Assessment
Scene size-up is not a static maneuver; that is, once completed at the onset of arrival to the scene, it should be constantly reevaluated--avoid complacency to maintain safety for you and the patient.
Baseline vitals should be acquired and include:
- analog pain score,
- blood pressure,
- heart rate,
- pulse oximetry,
- respiration rate and quality,
- blood glucose level,
- snapshot impression of the skin and pupils, and
- Glasgow Coma Scale score, when indicated.
S : Signs/symptoms.
A : Allergies.
M : Medication.
P : Past pertinent history.
L : Last oral intake.
E : Events leading to injury.
Pain descriptions should include a 1-10 pain score as well as:
O : Onset.
P : Provocation.
Q : Quality.
R : Radiation.
S : Severity.
T : Time.
Another helpful checklist is:
D: Deformities. C: Contusions. A: Abrasions. P: Punctures.
B: Burns. T: Tenderness. L: Lacerations. S: Swelling.
After completion of the assessment factors, the general impression of the patient is what the provider thinks initially of the situation.
Often, providers will attempt to silently determine “Sick or not sick?” and “Serious injury or non-life threatening?”
The general impression should not be verbalized but instead is the provider’s own gauge of the overall situation.