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“BASICS” OF BASIC SCENE ASSESSMENT

“BASICS” OF BASIC SCENE ASSESSMENT. Amy Gutman MD ~ EMS Medical Director prehospitalmd@gmail.com. OBJECTIVES. Systematic method of scene & patient assessment Look at cool photos…see how your eyes & gut lead to assessment & management strategies. BACK TO BASICS.

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“BASICS” OF BASIC SCENE ASSESSMENT

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  1. “BASICS” OF BASIC SCENE ASSESSMENT Amy Gutman MD ~ EMS Medical Director prehospitalmd@gmail.com

  2. OBJECTIVES • Systematic method of scene & patient assessment • Look at cool photos…see how your eyes & gut lead to assessment & management strategies

  3. 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

  4. 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

  5. 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

  6. 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

  7. MOTOR VEHICLE COLLISIONS • PDOF Patterns • Frontal • Lateral • Rear • Rotational • Rollover

  8. PDOF?

  9. FRONT END COLLISION INJURY PATTERN

  10. PDOF?

  11. “T BONE” PELVIC FRACTURE

  12. PDOF? Rollover

  13. UNRESTRAINED PATIENT W/ ROLLOVER

  14. 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 ?

  15. WARNING SIGNS • Fighting or loud voices • Weapons used / visible • Signs of drug use • Unusual silence • Knowledge of prior violence • Panic • Remember your inner voice

  16. 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

  17. SPECIAL CIRCUMSTANCES • Recognize early to rapidly request additional resources • Toxins • Crash scenes • Crime scenes • MCI • Water / Weather

  18. 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

  19. 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

  20. PROVIDERS’ ROLES • Data collection • Rapid assessment • Data analysis • Differential diagnoses • Data application • Treatment plan

  21. CLINICAL DECISION MAKING: GUTMAN’S PORNOGRAPHY PRINCIPLE

  22. SICK

  23. NOT SICK

  24. SICK

  25. NOT SICK

  26. LIKELY TO BE SICK

  27. 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

  28. DATA?

  29. 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

  30. WHEN DATA DOESN’T MAKE SENSE, ASK A DIFFERENT QUESTION

  31. ASSESSMENT?

  32. ASSESSMENT?

  33. INITIAL ASSESSMENT: AVPU • Begins with 1st impression • Evaluate patient, environment, appearance & activity • If patient has AMS • Glucose • Narcan • Oxygen • Head Trauma / CVA • Cardiac

  34. ABCDE PET PEEVES • Missed respiratory distress • Missed injuries • Fully dressed patients • Abnormal vitals with no explanation • Uncorrected symptomatic hypotension

  35. DON’T MISS THE FATA INJURY

  36. 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

  37. WTF INJURIES?

  38. 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

  39. SUBTLE FOCAL INJURIES

  40. 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

  41. DETAILED PHYSICAL EXAMINATION • Not Appropriate: • Critical injuries • Multiple Injuries • Short transports • Appropriate: • Long Transports • Prolonged Extrications • Awaiting Aeromedical Evacuation

  42. 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

  43. ASSESSMENT: THORAX & ABDOMEN • Chest: • Breath sound presence / quality, paradoxical motion, crepitus • Abdomen: • Firm / soft, masses, pulsations, tenderness • Pelvis: • Stability, crepitus

  44. DON’T MISS THE SECOND INJURY

  45. ASSESSMENT: EXTREMITIES & NEURO • Extremities: • Injury / deformity • Pulses • Movement • Sensation • Instability • Neurological: • GCS / AVPU • Deficits • Time • Type

  46. 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?

  47. 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

  48. 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

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