The primary assessment as taught to EMS students generally involves some combination of the ABC's, level of consciousness, a general impression of the patient's condition and a definition of treatment priorities for the call. This assessment still plays an important role in determining the flow of a call from start to finish.
The stepwise method taught in school is a great way to remember each phase of the assessment, but can take too long to complete on critical patients. While the primary assessment is taught — and tested — in a linear fashion, there are several ways that a provider can streamline the process. While in school you are required to perform many skills on your own, but practicing medicine as an EMS professional means that you have one or more additional providers at your disposal and you can expedite the process.
1. Multi-task ABC assessments
One reason why EMS students are required to perform each step of a task independently is that instructors and evaluators need a way to ensure that the student actually knows each of the steps involved. Once practicing on her own, however, an EMT or paramedic can find ways to combine steps to speed up the process.
Take the ABC's for example: when assessing a patient's airway, breathing and circulatory status you could certainly perform each evaluation one at a time. Consider, however, walking up, gently taking the patient's wrist to check for a pulse and asking his name. As soon as the patient speaks, you know he has a patent airway since air cannot effectively move past the vocal cords through an occluded airway.
The number of words spoken in a single breath and how the patient's voice sounds can give you some insight into his respiratory status. A patient wheezing and speaking two to three words per breath is struggling while a patient with a clear voice and speaking eight to 10 words per breath is breathing adequately. Also, you should have a general sense for presence and quality of pulse by now. Instead of taking the time to perform each step of the ABC's, you've completed them all at once.
2. Prioritize and delegate
Delegate certain assessment tasks to other EMS providers on scene. In the case of the choking patient, the primary provider may ask his partner to obtain a set of vital signs while she assesses the patient's ABC's. It isn't uncommon to see five or six EMS personnel standing around with only one actually performing any assessment or patient care. As with most decisions in EMS, pick the task that is most important to complete and assign that task first. In my experience, fire department first responders are often great recipients of task delegation because of their experience with chain of command on the fireground.
3. Correct and move one
Often taught alongside the ABC's is the idea that there are certain treatment interventions that should be performed during the primary assessment; generally limited to treatments which are considered lifesaving. While the goal is to complete the primary assessment quickly, it is important for the new EMS provider not to lose sight of the treatments which can and should occur during the primary assessment.
For instance, a patient without a patent airway should have that condition corrected immediately. Start with the least invasive approach or, better yet, delegate that activity and move on to your next assessment step. As a general rule, you should not move on to the next step (breathing) until the current step (airway) is corrected in a satisfactory fashion or has been assigned to someone. There may be calls where you spend your entire time with the patient attempting to manage airway and breathing and don't have a chance to move on to anything else.
Treatments performed during the primary assessment may include: airway maneuvers or adjuncts, assisted ventilations, chest compressions and bleeding control.
With the recent press coverage of EMS and law enforcement treatment of narcotic overdoses and the broadening of MFR and EMT scope of practice in many states to include naloxone, it may be tempting to consider correcting apparent causes of altered mental status during the primary assessment. While this thinking is not entirely incorrect, consider how that method allows other treatment priorities to be missed early in the call. In the case of hypoglycemia, fully understanding the scope of the patient's presentation requires obtaining a blood glucose measurement. For a suspected narcotics overdose, naloxone must be taken out of its storage area, assembled and administered. Both of these activities require multiple steps during which time a patient altered enough to not respond to EMS is also without a patient airway and potentially without adequate respiratory drive.
Instead, consider immediately identifying an altered mental status significant enough to compromise the patient's airway and reposition. Identify inadequate ventilation and assist with a BVM. This serves two purposes: the patient is not left in a hypoxic state unnecessarily and you can continue the primary assessment the same way on every call, correctable causes or not. Remember that practice makes perfect.
4. Don't get distracted
Your first several years in EMS are filled with new experiences. Many calls present some different aspect of assessment and patient care that you've never experienced before. It is easy to get caught up in the excitement and lose track of where you are in your assessment.
Sometimes, certain aspects of a patient's presentation may appear to be pertinent to the underlying condition, but wind up being trivial. Realizing that the primary assessment is geared toward establishing a general sense of the patient's condition it is important to remain focused on completing the assessment before treating the condition or presentation that demands the most attention. With the exception of lifesaving treatments mentioned above, the primary assessment should be completed without stopping. Newer providers may find themselves distracted by significant-looking orthopedic injuries that are far less severe than a closed head injury or significant chest trauma that may not be immediately obvious.
5. Big or little sick?
Since the guiding principle of the primary assessment is to characterize a patient's general condition, it is beneficial to think of their presentation in terms of "big sick" or "little sick." Many of the downstream decisions you will make on a call change based on the classification of the patient's illness. For instance, a "big sick" patient may need a shorter scene time, additional resources, a hospital pre-alert or even air medical transport. By contrast, a "little sick" patient could receive a more thorough evaluation on scene and be transported by a BLS ambulance to a less-specialized hospital.
The question of how sick a patient is does simplify a patient's presentation and sets the tone for the call. The patient priority or severity can always be updated as further assessment findings become available.
Case resolution
Immediately upon contacting Matthew, you can tell that he has a patent airway (he is able to speak) and appears to be breathing adequately. His pulse is strong and regular and you delegate a set of vital signs and a pulse oximetry reading to another responder. Your general impression of Matthew is that he is stable ― little sick ― at this time and that you can remain on scene to evaluate him further. As your assessment progresses, it becomes apparent that Matthew is not experiencing any immediate risk and that the quick thinking of the bystanders cleared his airway and prevented a much worse outcome. Once the ALS unit arrives and you provide a report, Matthew says that he has recovered and ultimately signs a refusal for transport.
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