Archive for June 2011
All patients must receive an initial assessment. The focused history and and physical examination that follows the initial assessment may differ somewhat depending on whether the patient has a medical or trauma condition. Most patients clearly fit into one of the two categories.
EMT’ Matt and Mary responded to a vehicle crash. The patient was sitting on the ground outside the vehicle talking to bystanders. Their scene size-up revealed no dangers to the EMT’s. The mechanism of injury was obvious as they looked around the scene: The patient’s car had struck a utility pole, causing moderate damage to the car. Bystanders had helped the patient from the car, and no other patients were involved. The initial assessment revealed that the patient was alert, had a patent airway, was breathing at a normal depth and rate, and ha a strong and regular pulse. Matt then moved on to the next step – the focused history and physical examination for trauma patients. The mechanism of injury was a front-end collision of a car into a utility pole. The insider of the vehicle seemed intact, but because of the amount of damage to the exterior. Mary realized that they must quickly evaluate the patient from head to toe to look for any unseen life threats not detected in the initial assessment. The mechanism of injury suggested that there might be serious hidden life-threatening injuries even though the patient seemed to be stable. Matt quickly evaluated the patient from head to toe to look for any unseen life threats not detected in the initial assessment. The mechanism of injury suggested that there might be serious hidden life-threatening injuries even though the patient seemed to be stable. Matt quickly evaluated the patient from head to toe, inspecting, palpating, and auscultating to assess for injuries. This rapid assessment was competed in 90 seconds. Matt and Mary determined that no life threats were present. The patient remained stable. They applied a cervical collar and moved him onto a long backboard and into the ambulance and began to transport to the appropriate facility. While en route to the hospital, Matt obtained the baseline vital signs and SAMPLE history.
EMT’s chuck and Tyra were dispatched to a home of a 65-year old woman who was responsive, breathing and experiencing chest pain. En route to the scene an EMT or Paramedic should consider what information they need to obtain immediately when they arrive. Had anything caused chest pain? What kind of pain was it? Did anything help relieve the pain? When did the pain start? Did the patient have any history of heart disease or heart problems?
On arrival Tyra immediately noticed the patient was sweating profusely and her breathing was labored. The patient said she felt a crushing sensation in her chest, and the tightness was making it difficult for her to catch her breath. Tyra questioned the patient and discovered that she had a history of heart disease and that the pain had started approximately 4 hours ago and did not subside after resting. She had taken one of her own nitroglycerin tablet but experienced no relief.
As Chuck took the patient’s vital signs and administered high-flow oxygen with a nonrbreather mask. Tyra decided that the patient would benefit by taking an additional nitroglycerin tablet. She contacted the medical direction physician and received an order to assist with the nitroglycerin. The patient felt some relief. They continued monitoring her vital signs and began transport immediately.
Note: Cardiac emergencies are the most prominent type of medical emergency in the United States today. Cardiovascular disease leads to more then 600,000 deaths each year, with half of those deaths attributed to coronary artery disease. Up to 50% of heart attack victims suffer cardiac arrest, and up to 50% of these arrests occur outside the hospital. Many of these victims can be saved if there is early recognition and the EMS systems can provide the CPR and early defibrillation.
Assessing a patient’s mental status is a little more complicated than simple stating, “mental…that one,” like Ron Weasley did in the first Harry Potter movie. Of course, it would be great to be able to make quick and general assessments. Assessing a patient’s mental status is an important step after the general impression is obtained. A mental assessment should only be made once the patient has been stabilized or immobilized, if a spine injury is present.
To accurately assess a patient’s mental status, the emergency medical technician should introduce himself to the patient and explain who he is and that he is there to help. Once this introduction is made the EMT should observe the patient’s reaction and response.
There are four categories that can be used to describe a patient’s mental status. The first category is alertness. Is the patient alert and interacting with the EMT without having to be prompted for information? The second category is verbal. Does the patient respond verbally when spoken to? The third category is painful. If the patient does not respond to either of the two previous categories the EMT should provide a painful stimulus to see how the patient will respond. The fourth category is unresponsive. If the patient does not respond to verbal or painful stimuli then the patient can be considered unresponsive.
The patient’s mental status can change at any time and should be observed regularly. It is important to note any changes that occur. If the patient becomes more or less responsive then the receiving facility should be notified and the patient’s change in mental status should be documented in the prehospital care report. A patient who has a deteriorating metal status may need airway support. An EMT should be prepared to provide aid to treat patients with signs and symptoms of shock, which can commonly occur and affect a patient’s mental status.
The general impression of a patient’s status is made when the emergency technician makes the first immediate assessment of a patient. This general impression can take place in a few seconds and usually helps the emergency crew to prioritize the patient’s care and plan of action. There are several important assessments that form the general impression.
An emergency medical technician should first determine if the patient has a medical condition or if the patient is injured. A patient with a medical condition may be wearing an alert tag that identifies the type of condition. These tags are often worn as bracelets or necklaces. If there is no alert tag available the EMT will have to determine the nature of the patient’s illness. If the patient is conscious, the EMT can ask questions or pick up on clues about the patient’s condition. For example, if the patient is complaining of shortness of breath he may be suffering from respiratory distress. Chest pain may indicate a potential cardiac emergency. The sooner you are able to classify the patient’s illness the easier it will be to treat the problem.
Often the first impression can accurately indicate if the patient is sick or not. This impression is usually made by the way that the patient appears, the position that the position is in or other physical attributes. This impression can help the EMT to determine if certain types of intervention should be performed to help improve the patient’s state.
If the patient is injured it is important to determine how the injury was caused. Was the patient involved in a motor vehicle accident? Did the patient fall or have burns? Determining how the patient became injured can give the EMT information about possible medical problems that could have caused the trauma, such as a heart attack while driving or a seizure causing the patient to fall. Making note of the patient’s age, gender and race can also help to form the general impression.
The last part of making an accurate general impression is to determine if the patient has any injuries that may be life-threatening. Examples of life-threatening injuries include: obstructed airway, inadequate breathing or circulation, major bleeding or any threat to the airway, breathing or circulation. These types of injuries should be corrected immediately.
A patient’s perfusion can be assessed by looking at the inside of the patient’s lips, the color of the patient’s nail beds or the skin that is just inside of the eyelids. These areas of the body are normally pink in all races of people. If any of these areas look pale, blue-gray, red or yellow than there could be a serious medical problem. A patient that appears blue-gray may be cyanotic. Red indicates flushed and yellow could be caused from jaundice.
Assessing infants and children under the age of 6 is only slightly different. To assess an infant or child, there are several areas that can pressure can be applied to, to evaluate the capillary refill. The nail bed, skin, heel or sole of the foot in infants can be pushed until the area appears blanched. Once the color is gone count how long it takes of the color to return to normal. If it takes longer than 2 seconds than there is a problem with profusion which may indicate shock, fever, hypothermia, or an underlying vascular disease.
The best way to assess a patient’s skin temperature is to place the back of your hand against the patient’s skin. If the skin feels warm and dry to the touch then the patient has a normal skin temperature. If the patient’s skin feels hot, cool, cold, or clammy then the skin temperature is considered abnormal. Unless there is an unusual circumstance, it is not necessary to take a thermometer reading of a patient’s temperature in the field. This can be done when the patient is in the hospital. How the patient’s skin feels can indicate a problem. Cool, clammy skin may indicate shock. If the patient has hot and dry skin then the patient may have a heat emergency, like heat stroke.
Evaluating a patient’s skin by observing the color, temperature and condition is one way of helping you to determine if the patient is experiencing a medical problem.
