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This course will expire or be updated on or before September 4, 2013.
ABOUT THIS COURSE
You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity.
ACCREDITATION / APPROVAL
Wild Iris Medical Education is an approved provider for paramedic and EMT continuing education in California by the Coastal Valleys EMS Agency: CE Provider #49-0057.
This course is appropriate for EMTs and first responders.
Wild Iris Medical Education, Inc. provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional health care. See our disclosures for more information.
This course is a review of EMT-B topics. For EMT certification training, contact your local EMS agency for information.
Copyright © 2010 Wild Iris Medical Education, Inc. All Rights Reserved.
This course is a review of material from Module 3 of the National Standard Curriculum developed by the United States Department of Transportation (NHTSA, 1997), and produced under the medical direction of Lisa MacCormack, MD.
Upon completion of this course, you will be able to:
The EMT-Basic will encounter patients who require emergency medical care. It is important to identify those patients who require rapid assessment, critical intervention, and immediate transport. The components of this module will assist the EMT-Basic in making patient intervention decisions.
You are called to the scene of an unresponsive patient. You arrive at a well-tended suburban residence and are met at the door by an anxious middle-aged woman. She tells you that she came home a few minutes ago and found her husband in bed, unresponsive. He had just finished breakfast when she left two hours ago and he was fine then.
Scene size-up entails an assessment of the scene and surroundings that may yield clues to the nature of the patient’s illness or injury. Ideally, it begins when you get the call. What can the dispatcher tell you about the call? (Keep dispatch information in mind, but don’t get tunnel vision once you arrive on scene. A single detail that the caller didn’t relate to the dispatcher can change your assessment of the incident.) To what area of town are you going? Is it an area known for gangs or violence? Is it a nursing home or senior living complex? Is it a busy downtown intersection or a stretch of rural highway that is a frequent site of severe crashes? Do you need extra resources immediately dispatched or placed on standby?
A good scene size-up will quickly identify elements that could make the scene unsafe. If you assess that the scene is not safe, don’t go in—call for additional resources. If you get there and the scene becomes unsafe, get out. “Heroes” who disregard dangers are part of the problem, not part of the solution.
Shootings, assaults, cuttings, and other reports of violence make a scene unsafe until proven otherwise. Situations involving psychotic patients may be unsafe. Further, situations where there is not enough information available to ensure that the scene is safe must be approached with extreme caution. Law enforcement should respond first to these scenes.
The presence, or suspected presence, of toxic substances is another opportunity for rescuers to become victims. Do not enter these scenes unless you have the necessary protective equipment and the training to use it properly. If possible, park your vehicle well out of the way of toxic environments and have patients brought to you once they have been properly decontaminated.
Approach crash scenes with care. These scenes can involve spills and leaks of substances that may be slippery or potentially toxic. Be alert for fire or downed power lines. Count the number of vehicles involved in the incident and get a quick look at the nature of the damage. Look for your patients. Are they trapped in the vehicle or walking around? How many accident victims are there? Order extra resources early.
Crime scenes should be approached only when cleared by law enforcement. While patient care is your first priority, don’t do anything that will destroy evidence unnecessarily. Only necessary personnel and equipment should enter the scene. Watch where you step. If you move or step on something, whether accidentally or on purpose, show law enforcement exactly what you did as soon as you can. Don’t worry—they realize that these things happen and are grateful when you report them promptly.
Consider your access and exit routes, both for your own safety in the event the scene later becomes unsafe and for practical purposes. Are the front steps to the house steep and unstable? Will slopes, ice, or other surfaces be an issue? Will the patient need to be protected from extreme weather conditions? If there is no easy or safe means of egress, you may need additional personnel to help move the patient.
There are many other factors to watch out for. For example, is the patient showing signs of abuse, neglect, or inability to care for self? Do you see pill bottles, drug paraphernalia, or empty alcoholic beverage containers? Can an object near the patient be used as a weapon?
Determine whether the problem is medical or traumatic. Be cautious in your assessment—and be open to changing your mind. A car wreck may have been preceded by a stroke or heart attack. Signs of trauma may be subtle if the patient is unconscious. Information about a medical patient’s nature of illness (NOI) may be determined from the patient, bystanders, family, or clues at the scene. How many patients do you have? Are there others in the house with similar symptoms? For instance, an entire family that comes down with “the flu” all at the same time should have you thinking about carbon monoxide poisoning.
With a trauma patient, you should have started assessing mechanism of injury (MOI) prior to patient contact. Determine the number of patients and call for additional resources before beginning any patient care. Determine how the patient was injured. Was it a fall, a car wreck, a machinery accident, or other MOI?
What can the scene tell you about the injuries to expect? Where is the damage on the car and how severe is it? How far did the patient fall and what did they land on? Do not neglect these observations, as they provide valuable information for the receiving facility in later treatment. The trauma surgeon cannot see the bent steering wheel or broken windshield, but they will know what injuries to look for if you give an accurate report. If spinal injury is likely, take precautions early.
Who else is at the scene? Are they potential patients? Will they be able to manage if you remove your patient from the scene? This is a frequent issue when the primary caregiver of a bedridden or dementia patient gets sick. The same concern exists if there are small children at the scene. If possible, do not separate parent from child. If separation is required, request additional resources such as a supervisor or police to transport the child to the same hospital to which the parent was transported.
Your patient is a middle-aged male who has the appearance of general good health but is unresponsive to any stimulus. His wife gives a history of borderline diabetes and a blood clot in his leg 6 months ago. His only medications are glyburide and warfarin. You partner has noticed a blood spot on the floor and walks back to the bathroom. He notices a rumpled bath mat and a spot of blood on the wall.
The initial assessment begins with the general impression of the patient(s) and is made very quickly. What you observe will guide your next steps. Look at the patient, their environment, their appearance, and their activity level, and ask yourself, Is this patient sick or not? With practice, this becomes something you will do without thinking. A patient who is sitting up and responds to your greeting has a patent airway, is breathing, and has a pulse.
Previously known as the A-B-C approach (Airway-Breathing-Circulation), American Heart Association guidelines now call for the C-A-B approach (Circulation-Airway-Breathing) when performing CPR.
If CPR is indicated, the revised standards from the American Heart Association (2010) have changed the order of this mnemonic to C-A-B (compressions, airway, and breathing). The philosophy behind this is to improve blood flow to the brain with the immediate initiation of chest compressions. Although the airway and breathing portions of CPR are still considered important, it is the actual blood flow from the chest compressions that will get oxygen to the brain.
Assess the patient’s circulation. A patient who is responsive and/or breathing adequately has a pulse. If the patient is unresponsive and not breathing adequately, feel for a pulse using the carotid artery for an adult and the brachial artery for an infant. Check for at least 5 seconds but no more than 10 seconds. Can you feel a radial pulse as well as a carotid pulse? Look for major bleeding and control it.
If you cannot feel a pulse, begin chest compressions on a medical patient. If you have a trauma patient without a pulse, follow your local protocol. Some systems consider cardiac arrest due to trauma incompatible with life and do not attempt resuscitation. If any doubt exists, begin compressions. Make sure your compressions are hard and fast, with good chest recoil.
Assess the patient’s skin. Note the color. If your patient has dark skin, examine the lips, palms, and nail beds. Look for normal pink color. Pale skin may indicate poor perfusion. Cyanosis (blue-gray skin) indicates a lack of oxygenated blood. Flushed red skin may be seen in hyperthermia and is a very late sign in carbon monoxide poisoning. Yellow or jaundiced skin is seen in liver failure. Is the skin warm or cool, taking the environment into consideration? Is the skin dry, moist, or wet? Check capillary refill. It should be less than 2 seconds in adults and children.
Assess the patient’s airway and open it if needed. If trauma is suspected, control the cervical spine and use a jaw thrust. If you can’t open a trauma patient’s airway with a jaw thrust, you may have to use the head tilt–chin lift method. With a medical patient, use the head tilt–chin lift. Does the patient show signs of an obstructed or partly obstructed airway?
Listen for noisy breathing. You may hear gurgling or snoring. Such patients often need an airway adjunct such as an oral or nasal airway. Stridor is a harsh sound from the upper airway that indicates a partial obstruction. Crowing is a high-pitched upper airway sound heard in children with a partial airway obstruction due to swelling. If you need to clear the airway, first try repositioning. Use suction as needed and place an adjunct airway if tolerated by the patient. If the airway is clear, can patients maintain it on their own? If not, insert an airway adjunct.
Check for adequate breathing. Adequate breathing is unlabored, with a rate and depth that will provide enough oxygen to the body. A patient who is breathing too quickly or too slowly may not be breathing adequately. Adults usually breathe 12 to 20 times a minute. Rates less than 10 or greater than 30 may not give adequate volume. Shallow respirations may not give adequate air exchange, even if the rate is fast.
Note any irregular respiratory pattern. Cycles of decreasing rate and depth followed by a period of apnea indicate serious distress. Lung sounds may be noisy or diminished. Absent breath sounds are a serious finding. The chest may not expand completely or may expand unevenly. This is often a problem with chest trauma. The work of breathing may be greatly increased. Agonal respirations are slow, gasping, ineffective breaths taken just before the patient becomes apneic.
If breathing is adequate and the patient is responsive, deliver oxygen if indicated. If the patient is responsive but not breathing adequately, give high-flow oxygen and be prepared to assist ventilation. If the patient is unresponsive and breathing adequately, make sure they can keep their airway open and use an adjunct airway if they cannot. (Place the patient in the recovery position if you do not suspect any trauma or spinal injury.) Give high-flow oxygen. If the patient is unresponsive and not breathing adequately, place an adjunct airway and provide ventilation with a bag valve mask (BVM) device using high-flow oxygen.
Once you have assessed the C-A-Bs, move on to the patients’ mental status.
If a patient does not seem to respond to you, assess for altered mental status. Maintain spinal precautions if indicated and gently shake the shoulder and speak to the patient. Use the AVPU scale.
|A||Alert||Patient has eyes open and talks to you|
|V||Verbal||Patient opens eyes to respond to voice, may or may not talk to you|
|P||Pain||Patient opens eyes or moves to painful stimulation|
|U||Unconscious||Patient does not respond to any stimulus|
With the information you have gathered so far, decide whether you have a priority patient. Any problem found in your initial assessment indicates a priority patient. This includes poor general impression, unresponsive or altered mental status, airway compromise, inadequate or difficult breathing, and inadequate perfusion or shock, which includes cardiac arrest, severe uncontrollable bleeding, and chest pain that is severe or accompanied by low blood pressure.
Transport priority patients immediately and request advanced life support (ALS) backup if available. With these patients, the focused exam can be done en route. If the patient is not a priority, you can proceed with a focused history and physical exam at the scene.
You apply oxygen and begin your assessment. The patient’s airway is open and he is breathing easily at 18 breaths per minute. He has a strong radial pulse of 60 and a blood pressure of 180/96. His oxygen saturation is 96% on room air. His wife is very familiar with the use of his blood glucose monitor and checks his blood sugar for you. It is 130, which she says is typical for him at this time of day.
The focused history and physical examination will give you more information about the patient’s condition and guide your treatment decisions. Ideally, the history is obtained from the patient. If the patient cannot answer your questions, some information may be obtained from family or bystanders. Use the mnemonic SAMPLE to assist you in getting a complete history.
For a trauma patient, most serious injuries will be found during the initial assessment. Any immediate threats to life should be treated as soon as they are found. Anyone who has sustained a major MOI should have a rapid trauma exam to ensure that no serious injuries have been overlooked. For a minor mechanism of injury, the exam can be limited to the area injured. For instance, someone who steps in a hole and breaks an ankle will not usually need a full trauma assessment.
It is important to develop a systematic approach to any physical examination. This helps to ensure a complete, organized, and efficient exam. Be sure to maintain spinal stabilization if indicated. If the patient is responsive, ask them what hurts or doesn’t feel right. Assess each major area for signs of injury. The mnemonic DCAP-BTLS is often helpful.
With most adults, begin by examining the head. In addition to the above signs of injury, look for blood or clear fluid coming from the ears or nose. When you assess the neck, look for the large veins on either side of the neck; these jugular veins should not be distended if the patient is supine. Apply a cervical collar if needed.
Next, assess the chest, watching it rise as the patient breathes. Look for unequal chest rise or paradoxical motion (one segment of the chest rises as the other falls and falls as the rest of the chest rises). Listen to breath sounds in the midclavicular and midaxillary lines bilaterally. Note absent, unequal, or noisy breathe sounds.
As you assess the abdomen, palpate in all four quadrants and note whether it is firm or soft. Note any distention or palpable masses.
Gently compress the pelvis to note any motion or tenderness.
Assess all extremities and check for distal pulses, movement, and sensation.
While maintaining spinal stabilization, log roll the patient and assess the back. Assess baseline vital signs.
Patients with medical complaints should have a rapid exam as well. If the patient is responsive, assess the history of present illness (HPI) and obtain a “SAMPLE” history (see above). Ask about signs and symptoms. Since injuries are not usually an issue for the medical patient, the focus of the examination is different from that for a trauma patient. The mnemonic OPQRSTis useful to recall questions to ask of medical patients.
Use the same systematic approach to assess the major areas of the body for medical patients as for trauma patients (see above). If the patient is conscious and gives you a specific complaint, limit your exam to that area. If the patient is unresponsive or their symptoms are vague, your assessment must be more complete. Assess baseline vital signs and determine treatment priorities based on your findings.
You identify this man as a priority patient, then request additional backup and begin a rapid exam. As you examine his head, you feel what seems to be an ice bag. You carefully log roll the patient and discover a bloody towel wrapped around an ice bag and a 1-inch laceration to the back of his head. The bleeding seems to have stopped.
Examination of the neck and back reveals no deformities. There is no deformity to his chest, and his lungs are clear and equal to auscultation. His abdomen is soft and his pelvis is stable. He has blood smears on his hands but no wounds or deformity to his extremities. You take spinal precautions, placing a cervical collar, long backboard, and head restraint.
You review the information you have obtained so far with his wife to ensure that you have it correct. You obtain the additional information that the patient has no allergy to any medication. You reassure the wife and make sure she knows which facility you are transporting her husband to and that she knows how to get there and has appropriate transportation. The patient is then moved to the unit for immediate transport.
A detailed physical exam may be performed on some trauma patients, typically en route to the receiving facility. It is used to gather even more information about the patient’s condition. It takes place following the focused history and physical exam and once all critical interventions are complete.
A detailed exam is generally not indicated for minor injuries. It may not be done for a critical patient with multiple injuries and complex concern. It will not be performed on short transports where time does not allow.
Follow the systematic approach described earlier, but now you will need more time so you can be more thorough. This is especially true with the head. Using the DECAP-BTLS approach, inspect and palpate the scalp. Palpate the facial bones and look at the face for asymmetry or swelling. Check the ears for drainage. Assess the eyes for discoloration, foreign bodies, or blood. Check the pupil size and reactivity to light. Assess the nose for drainage or bleeding. Assess the mouth for loose or missing teeth, swollen or lacerated tongue, or foreign bodies. Assess the neck again looking for distention of the jugular veins.
Assess the chest for paradoxical motion. Also feel for bony crepitus. This is the grating sensation felt when broken bone ends move against each other. Subcutaneous crepitus is a similar crackling or popping sensation of tiny air bubbles felt just beneath the skin in the chest or neck as a result of air leaking from a punctured lung and getting into the soft tissue. This is a serious finding. Reassess breath sounds.
Reassess the abdomen—is it firm or soft? Are any masses or pulsations palpable?
Check the pelvis for motion or crepitus.
Assess all extremities for injury as well as distal pulses, movement, and sensation.
Check the back if you can do so safely.
En route, you perform a detailed exam. The fresh bandage you placed on the head wound has no visible blood seeping through. There is no instability or crepitus around the wound. There is no wound, swelling, or deformity to the rest of the scalp. The facial bones are stable. The left pupil is midrange in size and briskly reactive, but the right pupil is dilated and reacts sluggishly. There is no blood or fluid from the nose or ears.
There are no foreign bodies, wounds, or blood in the mouth. The neck has no wound or deformity, and the trachea is midline. There is no bruising to the chest; the ribs are stable and there is no crepitus when you compress them. The lungs are clear and equal. The abdomen is soft, with no bruising or palpable masses. The pelvis is stable. The arms and legs show no wounds, bruising, or instability.
A good assessment is not an action but a continuous process that lasts for the length of the patient encounter. Once the focused exam and detailed exams are completed, go back and repeat your initial exam.
If the patient is responsive and stable, conversing with the patient demonstrates an airway and pulse, and the pattern of response gives an indication of mental status and ease of breathing.
For the unstable or unresponsive patient, go back and repeat the steps of the initial assessment at least every 5 minutes. Reassess every time you deliver or change an intervention. Repeat and record vital signs. Repeat a focused exam if indicated. For instance, additional swelling may cause a correctly applied splint to become too tight en route. Make sure that your oxygen delivery and artificial ventilations are adequate; don’t arrive at the hospital ventilating from an empty oxygen cylinder.
Check dressings to make sure bleeding is controlled. Use the ongoing assessment to reestablish priorities. Once major bleeding is controlled, it may be time for a splint somewhere else.
You reassess the patient. He remains unresponsive, with a patent airway and unlabored respirations. His blood pressure is 160/90, his pulse is 68, and his respirations are 18 bpm with an oxygen saturation of 100% on high-flow oxygen.
Verbal and nonverbal communication takes place with the responsive patient. Refer to a patient by his or her name. Begin by using a polite form of address, such as “Mr. Doe” or “Ms. Smith.” Patients will tell you if they prefer that you call them by their first name. (In some areas of the country, using a title with a first name, such as “Miss Mary” or “Mr. John” is considered a respectful form of address.)
Position yourself where the patient can see you easily if possible. Use a calm, quiet, confident voice. If others are raising their voice, lower yours; this helps calm the situation. Speak clearly and use language that patients can understand. Pace your questions so they have enough time to respond. If the patient is hard of hearing, don’t shout because it will distort your voice; instead, position yourself so they can see your lips and speak distinctly.
Be aware of you body language and use good eye contact. No one style will work for every patient. Be aware of the patient’s responses and body language and adjust your technique as needed.
Be honest with the patient, and don’t be afraid to say, “I don’t know.” Don’t tell them an intervention won’t hurt if it will.
Radio communications should take place prior to arrival at the receiving facility whenever possible. The receiving facility needs to know enough about the patient to decide what room to use and if any special resources (e.g., ventilator, trauma surgeon) need to be obtained. Communication should be done over a reasonably secure line and in a manner that does not identify the patient. Radio reports should be short, usually less than 30 seconds. Identify yourself and give your patient’s age and sex with a brief description of their problem. A current set of vital signs and a summary of your treatment and the patient’s response will usually be all that is needed.
Once at the hospital, introduce the patient by name and give a more detailed report to the nurse or other staff members who will assume care of the patient. This is the time to provide the medical history, list of medications and allergies, and any information about the scene that will be useful in the patient’s care. Be careful about where this communication takes place; crowded desk areas and curtained cubicles may allow protected healthcare information to be overheard by those not authorized to hear it.
Privacy laws dealing with protected healthcare information (PHI) apply to verbal communications as well as to written reports. Information that is protected by the Health Insurance Portability and Accountability Act (HIPAA) includes anything about the patient’s medical history and treatment. It also covers any information that can be used to identify a patient, including name, address, phone number, birth date, social security number, medical record number, and even their picture (HIPAA, 2001). This information may be shared with those who will be providing medical care to the patient, whether it is a hospital or other healthcare facility or another emergency unit. It should not be accessible to anyone not involved in the patient’s care.
Without the permission of the patient or their personal representative, you cannot give out any information about their condition. Many patients want close family members to take part in their care and will gladly share any medical information with them, but you must never assume anything. If the patient is unconscious, the situation becomes less clear. Your agency should have policies in place.
When communicating at the scene, use good judgment. Keep your replies as general as possible. Unrelated bystanders and curious neighbors should receive information from the patient or their representative only. If they ask you questions, a friendly “Someone’s not feeling well” acknowledges their concern but tells them nothing specific.
You may give law enforcement officers information about the identity of, or injuries to, suspects in a crime or victims of a crime if legitimately needed for their activities (HIPAA, 2001).
Filling out the paperwork may not have the excitement or the glory of running the call, but it is one of the most important aspects of your care and should be taken seriously. Complete, legible documentation will do more to keep you and your patients “out of trouble” on many levels than anything else you do.
The forms you use may be dictated by the state and will certainly be dictated by your service. They have many functions. The first is to provide continuity of care. Prehospital care becomes a part of the patient’s overall medical care and may affect care given to them hours or even days later. Your documentation becomes a part of the patient’s permanent medical record.
Documentation may also be used for educational purposes, as part of a case study, for research, or for quality improvement.
Your form is also a legal document. Even if your care is perfect, it may be called into question. It’s a common dictum that “if it wasn’t documented, it was never done.” Complete, legible documentation will hold up well in court; better yet, it may help keep your care from ever becoming part of a court case. You may be called to testify in court as to the patient’s condition or injuries if the patient became sick or injured because of a crime. In many cases this happens several years after the call, so you cannot rely on memory to fill in any missing gaps in your record. It is imperative that the document be both complete and accurate.
Falsification of information can cause you to lose your job and your license. It may adversely affect ongoing care of the patient. Errors in care occur; no caregiver is perfect. When errors do occur do, document what did or did not happen and what steps were taken to correct the situation. Never attempt to cover up errors. If vital signs were not taken, document the reasons; don’t make them up. If you forgot to administer oxygen, don’t document that you did.
While the layout and organization of the form may vary from one service to another, most have similar features. Written forms typically include lines to fill in, some check boxes, and a place to record vital sign, treatments, and a narrative. Many services are going to computerized forms using laptop or handheld devices.
The run data will include the date, times, service, unit number, and crew identification. Patient data will be demographic and include their name, address, birth date, race, and sex. The billing section will include information about insurance and guarantors, if indicated.
There should be a place for the nature and priority of the call as well as the location of the call. Additional information such as the chief complaint, treatment prior to arrival, signs and symptoms, exam findings, history, vital signs, care administered, and changes in condition may have a separate section or check boxes. Be sure to record times on vital signs and treatments.
Everything else should be included in the narrative. There are many good formats for the narrative. Your service may dictate which one you use. Otherwise, find one that works well for you that you can use consistently to give a complete, organized picture of what happened on the call. The narrative should be impartial. Describe what was said or what you found; don’t draw conclusions. If you were getting different stories from different people, report both sides and identify who said what. Include pertinent negatives—significant things that you did NOT find (e.g., “patient complains of chest pain but denies pain to the arm or jaw”). Also include observations about the scene: damage to vehicles, pill bottles, weapons, etc.
Your form should be easy to read. If you have poor handwriting, print slowly. If you cannot spell a word, look it up or use a different word. If you use abbreviations, make sure they are standard and do not use radio codes. If at all possible, complete your form prior to departing from the receiving facility and leave a copy. Follow local protocols for distribution of other copies.
You give a brief radio report to the receiving facility and continue to monitor the patient. Upon arrival you give a detailed report to the nurses accepting care. Document all findings and treatments in a careful, complete, and organized fashion.
You later find out the patient had bleeding that was causing pressure on his brain and resulting in his altered mental status and dilated pupil. You had suspected that the patient was at increased risk of this—with even minor head trauma—because of the warfarin medication he was taking.
The EMT-Basic will encounter patients who require emergency medical care. It is important to identify those patients who require rapid assessment, critical intervention, and immediate transport. This refresher course should assist with the quality of care that you are delivering.
American Heart Association (AHA). (2010). Handbook of emergency cardiovascular care for healthcare providers. Dallas: Channing L. Bete.
Health Insurance Portability and Accountability Act (HIPAA). (2001). Code of Federal Regulations, Title 45, Volume I, revised as of October 1, 2001.
Limmer D & O’Keefe M. (2009). Emergency care. Upper Saddle River, NJ: Pearson/Prentice Hall.
National Highway Traffic Safety Administration (NHTSA). (1997). Emergency Medical Technician-Basic: National Standard Curriculum. Retrieved from http://www.nhtsa.gov/people/injury/ems/pub/emtbnsc.pdf.
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