Emergency Medical Technician: Basic Refresher Curriculum

1
Emergency Medical Technician Basic Refresher
Curriculum

• Module III
• Patient Assessment

2
Cognitive Objectives

• Assess scene safely
• Recognize hazards/potential hazards
• Describe common hazards found at the scene of a
  trauma and a medical patient
• Determine if the scene is safe to enter

3
Cognitive Objectives

• Assess the need for additional resources at the
  scene
• Explain the reason for identifying the need for
  additional help or assistance

4
Cognitive Objectives

• Assess mechanism of injury
• Assess nature of illness
• Discuss common mechanisms of injury/nature of
  illness

5
Cognitive Objectives

• Perform an initial patient assessment and provide
  care based on initial assessment findings
• Summarize the reasons for forming a general
  impression of the patient
• Discuss methods of assessing altered mental
  status
• Discuss methods of assessing the airway in the
  adult, child, and infant patient
• Describe methods used for assessing if patient is
  breathing
• Differentiate between a patient with adequate and
  inadequate breathing

6
Cognitive Objectives

• Perform an initial patient assessment and provide
  care based on initial assessment
• Distinguish between methods of assessing
  breathing in the adult, child, and infant patient
• Describe the methods used to obtain a pulse
• Describe normal and abnormal findings when
  assessing skin color, temperature, and condition
• Explain the reason for prioritizing a patient for
  care and transport

7
Cognitive Objectives

• Obtain a SAMPLE history
• Signs and Symptoms of the present illness/injury
• Allergy
• Medications
• Past medical history
• Last oral intake
• Events leading to present illness/injury)

8
Cognitive Objectives

• Perform rapid trauma assessment and provide care
  based on assessment findings
• State reasons for performing rapid trauma
  assessment
• Recite examples and explain why patients should
  receive a rapid trauma assessment

9
Cognitive Objectives

• Perform a history and physical examination
  focusing on the specific injury and provide care
  based on assessment findings
• Discuss the reason for performing a focused
  history and physical examination

10
Cognitive Objectives

• Perform a history and physical examination
  focusing on a specific medical condition and
  provide are based on assessment findings
• Differentiate between the history and physical
  examination that are performed for responsive
  patients with no known prior history and
  responsive patients with a known prior history
• Differentiate between the assessment that is
  performed for an unresponsive patient or one who
  has an altered mental status and other medical
  patients requiring assessment

11
Cognitive Objectives

• Perform a detailed physical examination and
  provide care based on assessment findings
• State the areas of the body that are evaluated
  during the detailed physical exam
• Explain what additional care should be provided
  while performing the detailed physical examination

12
Cognitive Objectives

• Perform on-going assessments and provide care
  based on assessment findings
• Discuss the reasons for repeating the initial
  assessment as part of the on-going assessment
• Describe the components of the on-going
  assessment
• Complete a prehospital care report
• Apply the components of the essential patient
  information in a written report

13
Cognitive Objectives

• Communicate with the patient, bystanders, other
  health care provider and patient family members
  while providing patient care
• Discuss the communication skills that should be
  used to interact with the patient
• Discuss the communication skills that should be
  used to interact with the family, bystanders,
  individuals from other agencies while providing
  patient care and hospital personnel, and the
  difference between skills used to interact with
  the patient and those used to interact with others

14
Cognitive Objectives

• Provide a report to medical direction of
  assessment findings and emergency care given
• Explain the importance of effective communication
  of patient information

15
Affective Objectives

• Explain the value of performing each component of
  the prehospital patient assessment
• Recognize and respect the feelings patients might
  experience during assessment
• Explain the rationale for providing efficient and
  effective radio and written patient care reports

16
Psychomotor Objectives

• Demonstrate steps in performing scene size-up
• Demonstrate steps in performing initial
  assessment
• Demonstrate rapid trauma assessment used to
  assess a patient based on mechanism of injury

17
Psychomotor Objectives

• Demonstrate steps in performing focused history
  and physical on medical and trauma patients
• Demonstrate skills involved in performing
  detailed physical examination
• Demonstrate skills involved in performing
  on-going assessment
• Complete a prehospital care report

18
Module III Patient Assessment

• Scene Size-up/Assessment
• Definition - assessment of the scene and
  surroundings that will provide valuable
  information to the EMT-Basic
• Body substance isolation (BSI) review
• Scene Safety

19
Scene Safety

• Definition - assessment to assure the safety and
  well-being of the EMT-Basic
• Personal protection - Is it safe to approach the
  patient?
• Crash/rescue scenes
• Toxic substances - low oxygen areas
• Crime Scenes- potential for violence
• Unstable surfaces slope, ice, water

20
Scene Safety

• Protection of the patient - environmental
  considerations
• Protection of bystanders - if appropriate, help
  the bystander avoid becoming a patient
• If the scene is unsafe do not enter until hazard
  is eliminated

21
Mechanism of Injury/Nature of illness

• Medical
• Nature of illness
• Determine from the patient, family, or bystanders
  why EMS was activated
• Trauma
• Mechanism of injury
• Observations or information from sources on the
  scene

22
Mechanism of Injury/Nature of illness

• Determine the total number of patients
• If there are more patients than the responding
  unit can effectively handle
• Obtain additional help prior to contact with
  patients
• Begin triage
• If adequate resources are available at the scene,
  proceed to the initial assessment

23
Trauma

• Mechanism of injury - determine from the patient,
  family, or bystanders, and inspection of the
  scene the mechanism of injury

24
Trauma

• Determine the total number of patients
• If there are more patients than the responding
  unit can effectively handle,
• Obtain additional help prior to contact with
  patients.
• Begin triage
• If the crew can manage the situation
• Consider spinal precautions and continue care

25
Initial Assessment

• General impression of the patient
• Definition
• General impression is formed to determine
  priority of care and is based on the EMT-Basics
  immediate assessment of the environment and the
  patients chief complaint
• Determine if ill(medical) or injured(trauma)
• Age
• Sex
• Race

26
Initial Assessment

• Assess patient and determine if the patient has a
  life threatening condition
• If a life threatening condition is found, treat
  immediately
• Assess nature of illness or mechanism of injury

27
Initial Assessment

• Assess patients mental status
• Speak to patient. Tell your name, that you are
  EMTs, and that you are here to help
• Levels of mental status - (AVPU)
• Alert
• Responds to Verbal stimuli
• Responds to Painful stimuli
• Unresponsive - no gag or cough

28
Airway Status

• Responsive patient
• Is the patient talking or crying?
• If yes
• Assess for adequacy of breathing
• Rate, quality, depth
• If no
• Open airway
• Look, listen, and feel for breathing

29
Airway Status

• Unresponsive patient
• Is the airway open?
• If yes
• Support and reassess often
• If no
• For medical patients, perform the head-tilt
  chin-lift
• For trauma patients, perform modified jaw thrust

30
Airway Status

• Is the airway clear?
• Noisy respirations include
• Crowing
• Audible wheezing
• Gurgling
• Snoring
• Stridor

31
Airway Status

• Clear the airway
• Open the airway
• Suction the airway as needed
• Insert airway adjuncts

32
Airway Status

• For trauma patients or those with unknown nature
  of illness
• Stabilized C-spine
• Jaw thrust maneuver to open airway

33
Airway Status

• Is the airway clear?
• Not clear
• Noisy respirations
• Crowing, wheezing, gurgling, snoring, stridor
• Clear the airway
• Open airway, suction airway, insert airway
  adjuncts

34
Assess Breathing

• Assess the patients breathing
• If breathing is adequate and the patient is
  responsive
• Oxygen may be indicated
• All responsive patients breathing gt24 or lt8
  should receive high risk flow oxygen

35
Assess Breathing

• If the patient is unresponsive and the breathing
  is adequate
• Open and maintain the airway
• Provide high concentration oxygen

36
Assess Breathing

• If the breathing is inadequate
• Open and maintain the airway
• Assist the patients breathing
• Utilize ventilatory adjuncts
• In all cases oxygen should be used

37
Assess Breathing

• If the patient is not breathing
• Open and maintain the airway
• Ventilate using ventilatory adjuncts
• In all cases oxygen should be used

38
Assess Circulation

• Assess the patients pulse
• The circulation is assessed by feeling for a
  radial pulse
• In a patient 1year old or less, palpate a
  brachial pulse
• If no radial pulse is felt, palpate carotid pulse

39
Assess Circulation

• If pulseless, medical patient gtor 12 years old
• Start CPR and apply automated external
  defibrillator(AED)
• Medical patient lt12 years old or lt90 pounds
• Start CPR
• Trauma patient
• Start CPR if consistent with state or local
  protocol

40
Assess Circulation

• Assess if major bleeding is present
• If present, control bleeding
• Assess the patients perfusion by evaluating skin
  color, temperature, and condition
• The patients skin color is assessed by looking
  at the nailbeds, lips, and eyes
• Normal to pink
• Abnormal conditions
• Pale, cyanotic or blue-gray, flushed or red,
  jaundice or yellow

41
Assess Circulation

• Assess patients skin temperature by feeling skin
• Normal - warm
• Abnormal skin temperatures
• Hot, cool, cold, clammy, cool, and moist
• Assess the patients skin condition
• Normal - dry
• Abnormal - moist or wet

42
Assess Circulation

• Assess capillary refill in infant and child
  patients under 6 years old
• Normal capillary refill is less than 2 seconds
• Abnormal capillary refill is greater than 2
  seconds

43
Identify Priority Patients

• Poor general impression
• Unresponsive patients - no gag or cough
• Responsive, not following commands
• Difficulty breathing
• Shock (hypoperfusion)
• Complicated childbirth
• Chest pain with BP lt100 systolic
• Uncontrolled bleeding
• Severe pain anywhere

44
Identify Priority Patients

• Expedite transport of the patient
• Consider ALS backup
• Proceed to the appropriate focused history and
  physical examination (trauma or medical)

45
Focused History and Physical Examination

• Trauma
• Perform rapid trauma assessment on patients with
  significant mechanism of injury to determine life
  threatening injuries
• In the responsive patient, symptoms should be
  sought before and during the trauma assessment
• Continue spinal stabilization
• Consider ALS request
• Assess mental status

46
Rapid Trauma Assessment

• Continue spinal stabilization
• Consider ALS request
• Assess mental status
• Inspect and palpate DCAP-BTLS

47
Rapid Trauma Assessment

• Inspect and palpate
• Deformities
• Contusion
• Abrasions
• Punctures/penetrations
• Burns
• Tenderness
• Lacerations
• Swelling

48
Rapid Trauma Assessment

• Assess the head, inspect and palpate for
  injuries, signs of injury, or crepitation
• Assess the neck, inspect and palpate for injuries
  or signs of injury
• Jugular vein distention
• Crepitation

49
Rapid Trauma Assessment

• Apply cervical spinal immobilization collar
  (CSIC)
• Assess the chest
• Inspect and palpate
• Paradoxical motion
• Crepitation
• Breath sounds

50
Rapid Trauma Assessment

• Check breath sounds
• Apices, mid-clavicular line
• Bilaterally and at the bases
• Mid-axillary line, bilaterally
• Quality of breath sounds
• Present
• Absent
• Equal

51
Rapid Trauma Assessment

• Assess the abdomen
• Firm
• Soft
• Distended
• Assess the pelvis
• If no pain is noted, gently compress to determine
  tenderness or motion

52
Rapid Trauma Assessment

• Assess all four extremities
• Distal pulse
• Sensation
• Motor function
• Roll patient with spinal precautions and assess
  posterior body

53
Rapid Trauma Assessment

• Assess baseline vital signs
• Assess SAMPLE history
• Signs and symptoms of present illness or injury
• Allergies
• Medications
• Pertinent past history
• Last oral intake solid or liquid
• Events leading to the injury or illness

54
Rapid Trauma Assessment

• For patients with no significant mechanism of
  injury
• Perform focused history and physical exam of
  injuries based on components of rapid assessment
• Assess baseline vital signs
• Assess SAMPLE history

55
Responsive Medical Patients

• Assess history of present illness
• Assess complaints and signs or symptoms
• O-P-Q-R-S-T
• Onset
• Provocation
• Quality
• Radiation
• Severity
• Time

56
Responsive Medical Patients

• Assess SAMPLE history
• Perform rapid assessment
• Assess the head
• Assess the neck
• Assess the chest
• Assess the abdomen
• Assess the pelvis
• Assess the extremities
• Assess the posterior body

57
Responsive Medical Patients

• Assess baseline vital signs
• Provide emergency medical care based on signs and
  symptoms in consultation with medical control

58
Unresponsive Medical Patients

• Perform rapid assessment
• Assess the head
• Assess the neck
• Asses the chest
• Assess the abdomen
• Assess the pelvis
• Assess the extremities
• Assess the posterior aspect of the body

59
Unresponsive Medical Patients

• Assess baseline vital signs
• Position patient to protect airway
• Obtain SAMPLE history from bystander, family,
  friends prior to leaving

60
Detailed Physical Exam

• Patient and injury specific
• Perform a detailed physical examination on the
  patient to gather additional information
• As you inspect and palpate
• Check for DCATBTLS

61
Detailed Physical Exam

• Assess the head
• Assess the face
• Assess the ears
• Assess the eyes
• Discoloration, unequal pupils, foreign bodies,
  blood in anterior chamber

62
Detailed Physical Exam

• Assess the nose
• Drainage and bleeding
• Assess the mouth
• Teeth, obstructions, swollen or lacerated tongue,
  odors, discoloration
• Assess the neck
• Jugular vein distention and crepitation

63
Detailed Physical Exam

• Assess the chest
• Crepitation, paradoxical motion, and breath
  sounds in the apices
• Are breath sounds present, absent, or equal
• Assess the abdomen
• Firm, soft, distended

64
Module III Patient Assessment

• Assess the pelvis
• If no complaints of pain, gently flex and
  compress to determine stability
• Assess all four extremities checking for distal
  pulses, sensation, motor function
• Roll with spinal precautions and assess posterior
• Reassess vital signs

65
On-Going Assessment

• Repeat initial assessment
• For stable patient repeat and record every 15
  minutes
• For unstable patient repeat and record at least
  every 5 minutes

66
On-Going Assessment

• Reassess mental status
• Maintain open airway
• Monitor breathing for rate and quality
• Reassess pulse for rate and quality
• Monitor skin color and temperature

67
On-Going Assessment

• Re-establish patient priorities
• Reassess and record vital signs
• Repeat focused assessment regarding patient
  complaint or injuries

68
On-Going Assessment

• Check interventions
• Assure adequacy of oxygen delivery/artificial
  ventilation
• Assure management of bleeding
• Assure adequacy of other interventions

69
Verbal Communication

• After arrival at the hospital, give verbal report
  to staff
• Introduce the patient by name
• Summarize the information given over radio
• Chief complaint and history not previously given
• Additional treatment and vital signs
• Give additional information collected

70
Interpersonal Communication

• Make and keep eye contact with patient
• When practical, position yourself at a lower
  level than patient
• Be honest with patient
• Use language patient can understand
• Be aware of your own body language
• Speak clearly, slowly, and distinctly
• Use the patients proper name

71
Interpersonal Communication

• If a patient has difficulty hearing, speak
  clearly with lips visible
• Allow the patient enough time to answer a
  question before asking the next one
• Act and speak in a calm, confident manner

72
Pre-Hospital Care Report

• Function
• Continuity of care
• May not be not read immediately in the emergency
  department but may be referred to later for
  important information

73
Pre-Hospital Care Report

• Legal document
• Documents what emergency medical care was
  provided
• Status of the patient on arrival at the scene
• Any changes upon arrival at the receiving
  facility
• Person who completed the form may go to court
• Information should include objective and
  subjective and be clear

74
Pre-Hospital Care Report

• Educational - used to demonstrate proper
  documentation and how to handle unusual or
  uncommon cases
• Administrative
• Billing and service statistics
• Research
• Evaluation and continuous quality improvement

75
Pre-Hospital Care Report

• Use
• Types
• Traditional written form with check boxes and
  narrative section
• Computerized version where information is filled
  in by an electronic clipboard or similar device

76
Sections on PCR

• Run data includes date, times, service, unit, and
  names of the crew
• Patient data includes patient name, address, date
  of birth, insurance information, sex, age, nature
  of call, mechanism of injury, location of
  patient, treatment administered prior to arrival
  of EMT-Basic, signs and symptoms, care
  administered, baseline vital signs, SAMPLE
  history and changes in condition

77
Sections on PCR

• Narrative section
• Describe, dont conclude
• Include pertinent negatives
• Record important observations about the scene
• Avoid radio codes
• Use abbreviations only if they are standard

78
Sections on PCR

• When information is of sensitive nature, note
  source
• Be sure to spell words correctly
• For every reassessment, record time and findings
• Other state or local requirements

79
Pre-Hospital Care Report

• Confidentiality - the form and the information on
  the form are considered confidential in many
  states
• Distribution - local protocol and procedures will
  determine where the different copies of the form
  should be distributed

80
Pre-Hospital Care Report

• Falsification issues
• When an error of omission or commission occurs,
  the EMT-Basic should not cover it up.
• Instead, document what happened and what steps
  were taken to correct the situation.

81
Pre-Hospital Care Report

• Falsification of information on the prehospital
  care report may lead not only to suspension or
  revocation of the EMT-Bs certification/license
• Falsification affects patient care because other
  health care providers have a false impression of
  which assessment findings were discovered and
  which treatment was given.

82
Pre-Hospital Care Report

• Specific areas of difficulty
• Vital signs
• Document only the vital signs that were actually
  taken
• Treatment
• If a treatment like oxygen was overlooked, do not
  chart that the patient was given oxygen