Reading The Scene

1. Reading The Scene August 2012 CE Condell Medical Center EMS System Site Code#107200E-1212 Prepared by: Sharon Hopkins, RN, BSN, EMT-P

2. Objectives Upon successful completion of this module, the EMS provider will be able to: • 1. Describe components of the scene assessment/size-up. • 2. Describe benefits of the windshield survey. • 3. Define the term mechanism of injury. • 4. Describe common mechanism of injuries and potential injuries. • 5. Define nature of illness.

3. Objectives cont’d • 6. Describe the index of suspicion. • 7. Describe the 4 main impacts that occur in a motor vehicle collision (MVC). • 8. Define the term general impression. • 9. Describe the role of critical thinking or clinical judgment • 10.Describe the components of the primary assessment.

4. Objectives cont’d • 11. Given a scenario, determine a general impression • 12. Given a scenario, determine key questions to ask • 13. Given a scenario, determine the Region X SOP to follow • 14. Given a scenario, demonstrate the primary survey. • 15. Successfully complete the post quiz with a score of 80% or better.

5. Scene Assessment • Completed for every call you go on • Opportunity to gather information • Starts with scene safety • Is an on-going process and subject to change • Utilize your senses • Sight, hearing, smell

6. Scene Size-up • First part of any patient assessment process • Always begins with evaluation of scene safety • This includes medical and trauma calls • Evaluated in an on-going manner • Safety can be subject to change • After a scene size-up, you will have more patient involvement

7. Scene Size-up • Scene safety • Take Standard Precautions • Minimally gloves on all calls • What’s the mechanism of injury or nature of the illness? • Determine number of patients • Is there a clue that something more is going on? • Is there a need to activate the multiple patient plan? • Do you need additional help?

8. The “Windshield Survey” • Implies the survey taken prior to exiting the ambulance • Is the scene safe? • Are there any hazards you perceive? • If trauma, what clues are there regarding the mechanism of injury? • Will you need police for traffic or crowd control?

9. Mechanism of Injury - MOI • A force that produced an injury • A MVC at 45 mph • Can have common/anticipated injuries to certain situations • i.e.: orthopedic injuries from falls • Allows prediction of injuries and complications • i.e.: blow to the chest could cause a collapsed lung • Some injuries will be assumed present based on the MOI until proven otherwise • Cervical spine injury if the patient is complaining of neck pain after a fall from a height

10. Common MOI • Twisting injuries tend to affect • Hip • Femur • Knee • Tibia/fibula • Ankle • Shoulder • Elbow • ulna,/radius • Wrist

11. Common MOI • Forced bending or extension tend to affect • Elbow • Wrist • Fingers • Femur • Knee • Foot • Cervical spine

12. Common MOI • Direct blows may affect • Clavicle • Scapula • Shoulder girdle • Humerus • Knee • Hip • Femur

13. Common MOI • Indirect blows may affect • Pelvis • Hip • Femur • Knee • Tibia/fibula • Shoulder • Humerus • Elbow • Ulna/radius

14. Nature of Illness • Information obtained from a medical patient to help determine the possible problem with the patient • Information obtained from • The scene • The patient • The family members • Bystanders

15. Index of Suspicion • Use your “sixth sense” • Keep heightened suspicion and open mind • Be cautious of jumping to a diagnosis • Don’t be swayed by the patient’s opinion • “I’m not really hurt” • “It’s just a chest cold” • Anticipate the worse and hope for the best

16. MVC • With every one incident 3 collisions actually occur • A vehicle collision when the vehicle strikes an object • The body collision when the body strikes the interior of the vehicle • Organ collisions when the organs strike the interior surfaces of the body

17. Reading the Scene • The type of collision helps to predict the type of injuries most likely received by your patient • Knowing your anatomy, you can predict what body parts have been injured • You can then predict what signs and symptoms the patient is most likely to present • You are already formulating your treatment plan based on your anticipation of the injuries

18. Traumatic Mechanism of Injuries • Head-on collision • Rear-end collision • Side impact collision • Rollover collision • Rotational impact collision • Falls • Blunt trauma • Penetrating trauma

19. Reading the Scene • Your patient may not be aware of how they were injured • Gather clues as you approach the scene • What kind of damage to the environment do you note? • What marks on the body are giving clues?

20. General Impression • Your impression of the patient’s condition • Based on your scene size-up with mechanism of injury or nature of the illness (i.e.: the patient's chief complaint) • Based on the patient’s appearance • Meant to evolve as you gather additional data • Drives your decision on how to treat the patient

21. Practice Forming Your General Impression • Read the following 4 presentations • Determine what you consider the patient’s general impression to be • Determine which SOP(s) would be followed?

22. General Impression Presentation #1 A 60 y/o patient complains of burning chest pain for 2 hours with SOB • They are pale, diaphoretic and anxious • Your general impression? • Cardiac patient until proven otherwise • SOP to follow? • Routine Medical Care; Acute Coronary Syndrome

23. General Impression Presentation #2 • You respond to a school for a 6 y/o who fell off the jungle gym and is not acting right • The patient has vomited several times • Your general impression? • Head injury • SOP to follow? • Routine Trauma Care, Pediatric; Nausea Management

24. General Impression Presentation #3 • Your patient was stung by a bee while drinking from a can of soda • The patient has hives and is anxious • Your general impression? • Allergic reaction • SOP to follow? • Allergic Reaction • Will be able to determine specific level of reaction after further patient assessment

25. General Impression Presentation #4 • You are called to the scene for a mother in labor • Upon arrival the patient states they want to push • Your general impression? • OB delivery • SOP to follow? • Emergency Childbirth

26. Critical Thinking or Clinical Judgment • This is based on experience • The more experience you have the better your critical thinking skills are and the better your clinical judgment • These are difficult skills to teach • These are honed with experience • These can be improved by learning lessons from other calls • This is the development of your “sixth sense”

27. Primary Assessment • First step in any patient assessment process • Purpose – to determine any life threats • Typical progression is A-B-C • Perform C-A-B is the patient is apneic and pulseless following the AHA guidelines • Complete the primary assessment without interruption EXCEPT for airway problem or uncontrolled hemorrhage

28. Primary Assessment • Form a general impression • Assess the mental status • Include cervical spinal immobilization simultaneously if indicated • Assess the airway • Assess the breathing • Assess the circulation • Determine the transport priority

29. General Impression • What is the patient’s chief complaint • “Read the scene” for a traumatic event to get clues • Ask the patient what is wrong • Don’t rely only on the initial information from dispatch

30. Control of the Cervical Spine • Apply manual control/immobilization of the cervical spine if there is ANY suspicion of neck or spinal injury • A more detailed assessment will follow • Maintain manual motion restriction until the cervical spine has been cleared or until full motion restriction has been applied • Cervical collar, back board, head blocks • Can be used in medical situations also

31. Determine the Mental Status • Use the AVPU scale to determine the general mental status • A – the patient is awake • They may be alert and oriented or confused • V – the patient responds to verbal stimulation • Any slight movement is considered a response • P – the patient responds to some tactile stimulation with some kind of response • Watch for any small muscle movement including a twitch or moaning & groaning • U – the patient is totally unresponsive without any response at all

32. Assess Airway • Is the airway open? • Can the patient speak? • Do you hear any unusual noises? • Is suction required? • Limit to <10 seconds if suction must be used • Is there a need for any adjunct tools to be used?

33. Assess Breathing • Is the patient breathing? • Is there any evidence of distress? • If yes, do you consider it mild, moderate, or severe? • Does the patient meet criteria for supplemental oxygen? • Signs of respiratory distress? • When the pulse oximeter is applied, is it >94%? • Is there evidence that the patient needs ventilation support (i.e.: BVM)?

34. Assess Circulation • Were there any signs of major hemorrhage as you approached the scene? • Does the patient have a pulse? • What is the general rate & quality? • Do not spend time now yourself to actually count the heart rate!!! • Is there any hemorrhage that needs to be controlled?

35. Determine Transport Priority • How quickly do you need to initiate transport? • A stable patient allows for more treatment/interventions at the scene • A potentially unstable patient indicates more rapid transport with most interventions performed enroute • An unstable patient requires most interventions to be started while enroute • Perform only life-saving interventions at the scene

36. Practice “Reading the Scene” and Doing Your Job Read the following scenarios • Determine your general impression • Determine if there is any life threat • Is it actual or highly likely? • What more information may be needed during assessment? • Determine which SOP(s) you will need to follow

37. Scenario #1 • Your “windshield survey” as you are approaching the scene:

38. Scenario #1 • You are called to the scene for a 25 y/o female with a seizure • Upon arrival, the patient appears unresponsive • Lying on the ground • Audible gurgling, visible oral secretions • Responds to painful stimuli with moaning • Your general impression? • Adult with seizure activity who is now post ictal

39. Scenario #1- Critical Thinking • What could cause seizures? • Epilepsy? • Diabetic – most likely hypoglycemia? • History of head injury? • What is your priority of care? • Clear the airway • Positioning – side-lying • Suction • Consider need for cervical spine immobilization

40. Scenario #1 – Questions to Ask • Does anyone know the history? • Can witnesses describe the seizure? • Was the patient helped to the ground or did they fall?

41. Scenario #1 - Interventions • Protect the airway • Consider c-spine control if needed • Obtain a blood glucose level • Perform a head to toe assessment looking for evidence of trauma • Prior trauma that could cause seizures • Trauma from the seizure event

42. Scenario #1 - Critical Thinking • Which benzodiazepine is used to terminate active seizure activity per the Region X SOP’s? • Versed • Which route is preferred initially and why? • IN – to avoid inadvertent needle sticks • What is the dosage schedule for adults? • 2 mg IN/IVP/IO every 2 minutes titrated to 10mg • For peds: 0.1 mg/kg • For continued or recurring seizure, contact Medical Control (to repeat same orders to additional 10 mg)

43. Scenario #1 – Critical Thinking • If your patient is having a long term active seizure, how would you control/support the airway? • Positioning • Side lying to drain oral secretions • Suctioning • Limited to <10 seconds • BVM support • Diaphragm in spasm so patient's ventilations ineffective and too hard to evaluate quality of respirations

44. Scenario #2 – Windshield Survey • Your patient is in the car on the left

45. Scenario #2 • You respond to the scene of a MVC • Your windshield survey shows major front end damage with airbag deployment • The patient was unrestrained driver who is still in the car

46. Scenario #2 – Critical Thinking • What injuries are most likely with an unrestrained driver in a front end collision? • Great potential for injuries to all parts of the body • “Up and over” the steering wheel • Head and neck from windshield impact • Chest and abdominal organs from impact with steering wheel • “Down and under” the steering wheel • Knee, leg, hip injuries from striking the dash

47. Scenario #2 – Questions to Ask • What are the steps in the scene size-up? • Take Standard Precautions • Is the scene safe? • Number of patients? • What is the MOI? • Do I need help or specialized equipment? • When do you identify potential life threats? • By the time you get to the end of the primary assessment

48. Scenario #2 - Interventions • Immediate control of the c-spine • Provide airway & breathing assistance if needed • Consider need for supplemental oxygen • Determine transport priority • Guides decisions for interventions performed on scene versus enroute • Determine transport destination • Level I or Level II trauma center?

49. Scenario #2 – Critical Thinking • What are the evaluations performed for spinal clearance in the field? • Evaluate the mechanism of injury • Evaluate the signs and symptoms • Evaluate the reliability of the patient

50. Scenario #3 • You are called to the scene for an unconscious person • Upon arrival, you recognize the patient • You are frequently called for hypoglycemia • The patient is agitated, clammy, unable to follow commands • The family is unable to get the patient to eat or drink anything