# Medical Patient assessment: do I put NRMask on before OPQRST/SAMPLE?



## knighthonor (Oct 6, 2012)

Medical Patient assessment: do I put NonRebreather Mask on before asking OPQRST/SAMPLE questions?

watch?v=YtqOovwfK5g

I notice he put the mask on before asking questions.

in another video, somebody put it on after.

I been confused about this. Can the patient still talk with the mask on to answer questions?


also in the above video, when would you transport the patient? he said she was unstable, and high priority. 

would he continue to ask those questions, or transport her and ask on the way?


should he wait for assistance to pick the woman up to put on a stretcher?


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## Medic Tim (Oct 6, 2012)

I take it you are an emt student. Have you done any practice assessments in class or had one demonstrated for you yet? are you reading things from a book? have you looked at the NR or state skills sheets? my guess is you haven't.



  Most all programs follow the NR assessment which has little variation depending on what you find.They are taught as a systematic approach to find out what is going on/what you are going to do with your pt. Because of this, when you are testing they expect certain things to be done before others. Hopefully you are being taught to give O2 only when it is indicated and not to give everyone 15lpm via nrb just because you can.(same with boarding everyone but that is for another discussion) It can be hard to communicate with your pt when the nrb is on them. With your above example oxygenation if indicated would come before the SAMPLE/History. Once you are done class you will find things are not always done by the book depending on the pt and the provider. You will eventually come up with your own way/system of assessing pts.

I never watched the video as I cannot view videos at work.


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## knighthonor (Oct 6, 2012)

Medic Tim said:


> I take it you are an emt student. Have you done any practice assessments in class or had one demonstrated for you yet? are you reading things from a book? have you looked at the NR or state skills sheets? my guess is you haven't.
> 
> 
> 
> ...



no we havnt gone over any sheet in class.

we did a practice, but didnt go well.

if patient is having chest pains and a history of heart attacks, but it breathing ok, 
I give them O2 correct?

but before or after asking the OPQRST/SAMPLE?

the book doesnt answer this question. 

the videos are confusing since the two videos I watched show giving patient O2 at different times, one is before the questions, other is after.

in another video I recently watched showed some young lady emt giving the questions in the back of the truck.

iam confused.

if I give them O2 at first, do I later remove the mask to ask questions? seem strange to do so, but also seem strange to ask questions to them with mask on.


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## 7887firemedic (Oct 6, 2012)

First off print and study these:
http://www.nremt.org/nremt/about/psychomotor_exam_emt.asp

Bad link, cant watch video, oh well...

While NR is hardly how things are done in the field its a good starting point for students, and you have to pass the NR before you get to the streets anyway. 

Very rarely do pts need a nrb at 15lpm blowing in thier face although im sure in the nr testing for basic high flow 02 is standard treatment for all pts:thumbdown:
The way i start is mental status, complaint, bp,pulse,spo2 on a typical medical assessment. A room air spo2 is standard THEN o2 typically nasal cannula, if spo2 stays low or pt is gasping for breath, then a nrb might be appropriate.  Keep in mind the way, order, and rationale i do things may be different being a medic than what your taught as a basic. I titrate o2 based upon pt condition, chest pain pt at 100% spo2, pink, warm, and dry, adaquete breathing, and alert and oriented= low flow 02. Chest pain pt with 75% spo2, altered mental status, cyanotic, etc.... High flow o2 with nrb. You will learn how to classify and meet your pts needs during your class. Assessment is priority #1! Without a good assessment you cannot properly manage any pt.


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## Shishkabob (Oct 6, 2012)

Fix life threats as you come upon them.  NREMT still beats the "ABC" horse to death.


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## Aprz (Oct 7, 2012)

If you go by NREMT's criteria, you will at least consider administering supplemental oxygen prior to OPQRST/SAMPLE.

I use the mnemonic ABC123 to remember most of the initial assessment (after sizing up the scene). ABC123 is a checklist. A, airway, 1 criteria. B, breathing, 2 criteria. C, circulation, 3 criteria.

(A) Airway
    1: Is it opened?
(B) Breathing
    1: Describe their breathing.
    2: Consider oxygen.
(C) Circulation
    1: Severe bleeding?
    2: Palpate radial pulse.
    3: Obtain skin signs.

I hope that answers your question. I think I am gonna go further by explaining some tricks for patient assessment, tell you how I say it, and hope that will help you. I am gonna explain things how I think the NREMT rationalize stuff, but some of this, I don't agree with. I will try to share some alternatives too.

You're gonna start by sizing up the scene. It's suppose to be like a funnel, and help you narrow things down. You will look at the entire scene like one big picture before you narrow it down to the patient. Both in real life and in test, the scene in general is gonna give you an idea about your patient and possibly what's wrong with them. What kind of patient do you think you have if they are sleeping on a park bench? What kind of patient do you think you have if they are in some sort of crack house? Etc.

The first part of the patient is assessment is going to be body substance isolation (BSI), or some people say personal protective equipment (PPE). This is when you would wear gloves, glasses, mask, gown, or safety equipment like a helmet or jacket. Your safety comes first.

After BSI, check if the scene is safety. Again, your safety comes first.

Then determine the mechanism of injury (MOI) or nature of illness. If somebody is on the ground, think of ways they ended up there? Is there a latter near by that they may have fell off of? Did they have a syncope (faint)? Did they get pushed/attacked? I think this comes next because you're suppose to think can whatever hurt the patient hurt me? It's a part of scene safety.

Number of patients. Pretty straight forward, but why is it after determining the mechanism of injury?

Determine need for additional resources. How are you suppose to know how much ambulances you need if you have figured out how much patients there are? That's probably why number of patients comes before additional resources. This is gonna be a good time to figure out what has already been dispatched and who is already on scene. If you are dispatched for a gun shot wound (GSW), are police already on scene and consider it safe?

Last is taking spinal precautions by hold c-spine, and usually this is gonna be delegated to your imaginary partner, or whoever is on scene if you want to keep your partner available for something more important (for some reason, they made this a big deal at my school). This is pretty much when you actually get into contact with the patient which is why it's last, and by NREMT criteria, you're probably not gonna hold c-spine until without figuring the MOI which means it's important to figure out the MOI before holding c-spine, or if it's unknown, to take precaution until it can be cleared.

Some people are taught an acronym to help them remember all the criteria in scene size up plus one more that is not included in the NREMT, it's called ENAMES. I think it's a Fire and local thing here. The E is for environment, scene safety and just looking at the scene, N for number of patients, A for additional resources, M for MOI, E for extrication needs, and S for spinal precautions.

For extrication needs, I see a lot of people thinking about how they are gonna get to their patient and take them out of the scene e.g. are they trapped in a car. I like to think for simpler things like is the patient where I can effectively assess and treat them e.g. somebody in a narrow hallway, or somebody in between the bathtub and toilet, I am probably gonna want to move them to a different spot.

So at one of the schools I went to, you'd hear people say something like

_BSI
E: Scene safety
N: I see one patient.
A: I do not need additional assistance right now.
M: The mechanism of injury is unknown.
E: There are no extrication needs.
S: I am going to delegate to my partner to hold manual c-spine._

(They wouldn't actually say the E, N, A, M, E, S before saying those unless it helped them remember what they had to say. They'd generally just say what they have to say.)

or they'd say

_BSI
Scene safety.
The MOI is unknown.
There is one patient.
At this time, I don't need additional assistance.
I am going to delegate to my partner to hold manual c-spine._

Personally I don't like to take spinal precautions unless the dispatch information or MOI indicates it. I got dinged at school for not having my imaginary partner hold c-spine because we were dispatched for "unknown medical", and I think it's really dumb to hold c-spine for something like that. I expect that there are lot of instructors like that though so just consider that you might get dinged for doing something stupid like hold c-spine for unknown medical, or you might get dinged for not holding c-spine of unknown medical, lol. This contributed to why I didn't like school and some skill instructors.

Another dumb thing at school that they would do to me sometimes was if I didn't ask for additional assistance or determine what I had on scene already, they would make it so I was the only person on scene, no partner, or they'd make the patient crash in the middle of the scene, and be like "You don't have a partner". When you asked for it later, "Dispatch says that Fire/EMS won't be there for another 20 minutes." They threw some really dumb curve balls at me. I felt this was really unrealistic and contributed to why I didn't like school and some skill instructors.

That would be the end of sizing up the scene. In both real life and in school, you should constantly be re-evaluating the scene. You can ask for additional resources as needed, abandon the scene or "scoop and go" if it becomes unsafe, etc. I think technically, if you forget to do any of this in the beginning prior to your initial assessment, it's a critical criteria, and you'll automatically fail even if you say it later.

Now comes the initial assessment. You're going to "check and correct" anything that could kill your patient within minutes, and this will be part oof your decision in whether this is going to be a "scoop and go"/"load and go", or if it's gonna be a "stay and play" situation. If you cannot correct a lot of these criteria, it's probably gonna be a load and go situation per NREMT criteria.

You're still in the middle of contacting the patient, but not quite yet. You're gonna form a general impression. What does the patient look like? Generally they are gonna want you to verbalize the patient's approximate age, their position, where they are at, and their level of distress.

Now you make contact with the patient, you introduce yourself first. Usually your name, your level of training, and the company your work for (although that's pretty excessive in my opinion).

Now that they know who you are, your level of training, and who you work for, they can make an inform decision and consent to you helping them. This is actually kinda tricky by you really need to know if the patient is oriented or not in order for them to refuse, and in a lot of areas, age is important too. Also if they are some sort of psychiatric hold, they might not be able to make decisions for themselves. This part of the initial assessment is all merged with the next part. Also at my school, they disliked that I straight up asked for permission to help "Can I help you?" They tried to convince me not to give them that option. I really disliked that, but I expect other schools might give people trouble for that. An okayish alternative, but isn't very blunt, is "What can I help you with today?" which a lot of people in my area think is gold, and maybe it is, I am not sure.

All while you were walking up to them and they were tracking you with their eyes, they are aware of your presence, and that means they are alert, but you haven't necessarily determined if they are oriented yet. If they aren't alert to you, you are going to check in order if they response to verbal stimuli (talking to them) or painful stimuli (sternal rub, trapezius pinch, shake, etc), or if they are unconscious/unresponsive (the acronym here is AVPU: Alert, Verbal, Pain, Unconscious. I regularly hear it as Ahv-poo.)

Determine their chief complaint. Why did they call? What is their primary complaint?

Then you do ABC123! Refer to the top of the post for that.

Check their orientation. Ask person, place, time, and event. For each one they get, they get a point for it, and they'll report it is "A and O times (number of points)". It might be written like "AOx4", "A+Ox4", "A&Ox4", they might have conscious in the beginning "CAOx4", and some places don't use event so 3 might be their max. I've heard of person, place, purpose, and time instead too. I actually purpose and use that for event regularly and combine it with place "What brought you to (name of place)?" or "Why are you here?" I think is a good one. Some people ask lame things like "Who is our current president?" or "How many dimes are in a dollar?" for event. I dislike that. I personally like to just talk to my patients in real life and I'll slip in like a sly mofo like I do with asking event. My conversation might go like "Hi, my name is John, I am an EMT, what's your name? (name), what can I help you with today? Oh, how long has that been happening for? (throw in something about place later on)." I am not blunt with these questions like I am with consent, and usually I ask for consent after I figured out what's going on and before I touch them, and I'll get them to sign the consent form right then and there letting them know that they are in charge and can accept/deny any treatment and it's up to them whether they want to be transported or not after I assess them. It may depend entirely on where you live, company policies, etc. I am gonna give you an example later on, but it's gonna be very blunt, and it's gonna be NREMT style.

After determining their orientation, one of the two schools I attended determined the glascow coma scale (GCS). Real quick I'll rattle off the criteria/tricks, minimum is 3, max is 15, there are three different categories, minimum for all three category is 1. Memorized the max saying "4 eyes, jackson 5, V6 engine", 4 eyes" is what some people say to make fun of people wearing glasses, has to do with eyes, 4 is the max point for eyes, jackson 5 is the band michael jackson was in, they sing, 5 is the max for verbal, and V6 engine will hopefully make you think of a motor, max for motor is 6. For eyes, it's AVPU. A = 4, V = 3, P = 2, U = 1. For verbal, the difference between 5 and 4 is whether they are AOx4 or not. They are gonna be clear, understandable, but 5 if they are AOx4, or 4 if they less than AOx4. If they are saying words that you know, but it's not appropriate e.g. you ask them "What's your name?" and they say "I like pancake on bunny head", they are gonna get a 3. If it's slurred speech/moaning/not very understandable, it's a 2. No sound is gonna be a 1. Motor is a little bit more difficult, it's follow commands (6), appropriate response to pain (5), inappropriate response to pain (4), decorticated (3), decerebrate (2), no response to painful stimuli (1). I can go into depth on this for you more if you'd like, I wanted to briefly go over it in case your school does go over it and includes it, but most schools don't go into it, and I think a lot of people just straight up don't know it. It was intended on being used for head injury only, but it's so easy to calculate it can be done by the initial assessment, and it's actually a pretty good neurological assessment to do on everyone in my opinion. This may or may not be include in your school initial assessment, I doubt it is, and it's not in the NREMT I think either. I still say it anyhow, lol.

Some schools might want you to verbalize the reliability of the patient. This might change the order of your patient assessment later (along with whether it's a significant MOI or not). The patient can be unreliable if less than A+Ox4 or aren't alert.

After all of that, you need to make a transport decision, is this gonna be a load and go or stay in play. This is based on whether they are a high priority e.g. "big sick" they are severely bleeding, they aren't breathing, airway can't be controlled, poor skin signs, etc., or if they are a "little sick", everything is fine in the initial assessment, but they have tummy pain or something, lol. Most people are gonna be "little sick". I think the only thing in here that's not gonna make them a high priority if they fail it is orientation status, although it can. A more in depth assessment is gonna be somebody with an abnormal orientation status a low or high priority, and you probably won't figure that out by the end of the initial assessment.

So for the initial assessment, I generally hear something like this

_I see a 50-year-old male sitting semi-fowler's in his living room couch, clutching is chest (levine's sign) in mild distress.
"Hello, my name is Roy, I'm an EMT with XYZ ambulance company."
"Can I help you? What can I help you with?"
The patient is responsive/alert, and his chief complain is chest pain.
Because he is talking to me, I know his airway is open and unobstructed.
His breathing is quiet, unlabored, and regular with good tidal depth, however, I am going to administer oxygen by non rebreather mask 15 liters per minute.
I see no severe bleeding.
"Can I see your wrist? I am going to check your pulse."
His radial pulse is strong and regular.
Skin signs are pink, warm, and dry.
"What's your name?"
"Where are you?"
"What month is it?"
I've already determined event, the patient is having chest pain.
GCS 15, Eyes opened 4, A+Ox4 so Verbal 5, and Motor follow commands 6.
The patient is reliable and a low priority, I am going to stay and play._

The parts in "quotes" are you talking to the patient. The rest is you verbalizing to the proctor. Obviously slash out parts that your school is not gonna include, the NREMT isn't gonna include (i.e. I don't think the NREMT includes the GCS).

I personally don't believe a patient should get a non rebreather mask just because they are having chest pain.

I don't think it's part of the national registry, but to assess airway, some schools, skill instructors, etc., will want you to check breath sounds while assessing ABCs. In real life, I usually check breath sounds in the beginning of my assessment, but only because it's difficult to hear on the road, and I really do listen carefully whether I hear anything while inspiratory or expiratory, it's location, try to figure out how long I hear the sound so if it's vesicular, bronchovesicular, or bronchial, and I haven't listened to trachial sounds yet (put the diaphragm over the patient's trachea) on an actual patient yet, but pretty much make sure I hear the appropriate sounds where they are suppose to be. Anyhow, breath sounds is a good way to assess their airway.

Hopefully that's not too much for you, and hopefully it's helpful.


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## Aprz (Oct 7, 2012)

So for more lols, I'll tell you some more since I am pretty bored.

At one of the two schools I attended, they wanted me to immediately to determine c-spine if it can be cleared "Did you fall? Did you blackout? Do you hit your head? How did you fall?" to clear my partner from manual c-spine. They also wanted my partner to immediately take baseline vitals for me, and later on in the assessment, ask my partner what they got. Sometimes they wanted me to be very specific and tell my partner I want a heart rate, respiratory rate, and blood pressure. So if your school is like that, do that. I don't like that, but it's whatever.

Depending on your school, your order could be the typical SAMPLE -> physical exam -> vital signs -> ongoing assessments, or the order can change based on whether the call is medical or trauma, if it's a significant MOI or not, or if the patient is reliable or not. If that's the case, the order they taught me was

Unreliable patient and/or significant MOI
1. Rapid physical exam
2. Vital signs
3. SAMPLE

Reliable medical patient
1. SAMPLE
2. Focused physical exam
3. Vital signs

Insignificant MOI trauma patient
1. Focus physical exam
2. Vital signs
3. SAMPLE

I'm not sure if the order matters to the NREMT for this. I personally always did it in the above order. This may vary by school too. This is going by the Nancy Caroline books or whatever they are called I think.

Pretty standard order though (without considering MOI and/or reliability of the patient is) is SAMPLE: Signs & Symptoms, Allergies, Medications, Past Medical History (PMH or PMHx), Last oral intake, and Events leading up to calling 9-1-1. To get signs and symptoms (mainly symptoms at this point since you are talking to the patient, but they might tell you about some signs e.g. sputum), you are going to ask OPQRST, PASTE, PASTEMED, OLD CARTS, PODD, etc. We have an acronym list somewhere on this forum where I mentioned what these means and people have different variations of them, look it up. You might ask things like "Has this happened before? Did you see a doctor for it? What did he have to say about it?" or ask more close ended questions and very specific things that aren't about pain or shortness of breath like the two acronyms they teach in EMT school like "How long was the patient seizing for? What did it look like? Did he fall?" See what I mean? For altered mental status, or for strokes more importantly, it's gonna be important to ask when was the last the time the patient was seen normal. I highly recommend looking up the AHA criteria for clot buster treatments for strokes and STEMIs "Has he had a stroke recently?", "Is he on any blood thinner medications?", etc, that's gonna be huge to relay to the hospital in your report and save time, don't delay transport for those guys more than what you have to, and for the stroke patients, I recommend transporting with somebody who can be a representative for the patient at the hospital and also be a witness that the hospital can hear from saying when was the last time they were seen normal (this is more huge in real life than in testing and the NREMT, but I want you to start thinking about it, and it might be nice to include in testing anyhow although you want to consider that you are being timed). For allergies, ask about what happens when they are exposed to that allergen. For medications, ask about over the counter, prescription, recreational, herbs, and supplements. For past medical history, correlate it with the medications they take. The patient might say they don't have any medical conditions, but when you ask which medications they are taking, they'll say "Atenolol, Coumadin, Valium, blah blah blah" so obviously they do have some sort of history. You can clarify it "What do you take those for?". For now, not knowing home medications will be a requirement at your school, but it's gonna help with obtaining a history if the patient says they have none, or if they are altered, check their drug cabinet in the bathroom. I think last oral intake is only really a big deal with hypoglycemic emergencies, I've heard it's a big deal if the patient is gonna get surgery, but I am not sure how true that is. Events leading up to might be merged with signs and symptoms, and events in your initial assessment. Usually at this point, I also ask age in the testing scenario. In real life, age is one of the first few things I ask.

There are different physical exams. There is focused, look at the area of complaint, or more importantly, assess for pertinent positives and negatives e.g. if the person is complaining about chest pain, an okay thing to do is check only the chest, but a pro student is probably gonna check the head for nasal flaring, pursed lips, facial expression, jugular venous distension (JVD), neck veins, platysmal indrawing, symmetrical rise and fall of the chest, breath sounds, intercostal retraction, signs of trauma (DCAPBLSTIC), pacemaker, nitro patch, pedal edema, discoloration at or below the chest and check the patient's blood pressure on both sides cause they are trying to rule in or out angina, an myocardial infarction (MI), shortness of breath (SOB), congestive heart failure (CHF), and a thoracic aneurysm. There is more, but that's just the basics of it! See how it's a focused assessment at least? Most people think focus is just one region, but it's really just looking for signs to rule in or our what you think it is so any part of the body.

A rapid physical is like a full, but only the kill zones, so pretty much only the distal extremities are left out. You check the full head, neck, chest, abdomen, pelvis, proximal extremities, and posterior.

And then a full physical. You will typically do this during your ongoing assessment while transporting, but a lot of people just do the full during the physical exam in their test, and they practice this in school like that. Before each region, you will verbalize "Looking for DCAPBLS, feeling for TIC" except at the abdomen it's "Looking and feeling for DCAPBTLS". A lot of schools don't even use DCAPBLSTIC, they'll say DCAPBTLS for each region instead.

I kinda expect a EMT basic full physical exam to be something like

Head, Eyes, Ears, Nose, and Throat (HEENT): Look for head and facial symmetry, check for blood when palpating, Battle's sign/Racoon eyes, sclera white, pupils 4 mm equal, reactive, round to light 2 mm, and accommodate (look up accommodate, people usually don't know what this is and don't assess it, but they still say it), check for injury or debris in the eyes, contact lenses, cataracts, do they follow movement equally, moist or dry, nystagmus, nasal flaring, singed nares, foreign objects, blood, cerebral spinal fluid (CSF) in nose or ears, burn around mouth (I forget how to word this all of the sudden, what people usually say at least), symmetry of the tongue (are the making an O sign or Q sign? Just kidding... a little), bit tongue, foreign objects or blood in the mouth, oral hydration, and if teeth are intact.

Neck: Trachea midline, subcutaneous emphysema, stoma, medic alert tag, JVD, accessory muscle use (platysmal indrawing or strenocleidomastoid), neck veins distending.

Chest: Supraclavicular indrawing, intercostal retraction, pacemaker/AICD, nitropatch, equal rise and fall, assess breath sounds (bare minimum 2 breadths midclavicular from clavicle and about 6th intercostal space (ICS) midaxillary is what I was taught), excessive chest movement, subcutaneous emphysema also.

Abdomen: Distention. Is it soft and non tender? Pulsating mass (I was told not to touch it if it's pulsating). Palpate in the 4 quadrants or 9 regions (learn the 9 regions if you don't know it, it'll help you relay more exactly where the pain is and better form a differential diagnosis (DDx), which isn't the final diagnosis (Dx) doctors make and not the whole "we don't diagnose" thing). I hear Cullen's sign thrown around and McBurney's point mentioned sometimes.

Pelvis: Urinary/Fecal incontinence, priapism, rectal or vaginal bleeding if applicable.

Extremities: Check for track marks, and assess CMSTP: capillary refill, motor, sensory, temperature, pulse. I've seen a lot of variations of CMSTP e.g. CMS, PMS, etc. A lot of times, C is circulation instead. Look for medical alert tags on wrist and feet. Check for pedal edema at the feet. Sometimes I hear clubbed fingers tossed in. You can toss in equal grip test too and pronator drift if you suspect stroke (palm face up when you have them hold up their hand)s in front of them for 10 seconds and their eyes closed).

Posterior: Symmetry and sacral edema. Breath sounds paravertebral from above the scapula, mid scalpula, and below it I think is the easiest way for me describe it, not over the bone.

In regard to breath sounds, there are a bunch of spots so what I am saying may not apply to what your school teaches. In fact, one school I went taught only 4 spots and looked at me like I was crazy for doing 6 spots on the back, and the other school taught 6 spots. I think Bates' Guide to Physical Exam and History taking has like 14 spots on the back, lol. Your goal is mainly general area like listening to the apical, middle lobe, and the base of the lungs. I hear back is gonna be easier to hear, but personally, I like listening to the front more.

For vital signs, I was taught heart rate, respiratory rate, and blood pressure at one school, but at another school, taught heart rate, respiratory rate, blood pressure, pupils, skin signs, and capillary refill. Personally, I like to think CTCTC with skin signs: color, temperature, condition, turgor, and capillary refill (so I consider capillary refill a part of skin signs), usually hear "moisture" instead of "condition". Another handy acronym I have heard is PRBELLS (look it up in that acronym list I mentioned earier) for VS, but I use it more for ongoing assessment. Also for the pulse, you should get the rate, rhythm, and quality. For respirations, rate, rhythm (check out things like Cheyne-Stokes, Biots, etc), effort at minimum, I include audible sounds, and one of my schools wanted me to say something like "good tidal depth". I think I pretty much covered everything else with vital signs. Don't forget to ask what your partner got for baseline if you had them do that.

Treat acccordingly, transport, is it gonna be with or without red lights and sirens, which hospital are they going to, if the patient is critical, reassess every 5 minutes, if not, every 15 minutes, and you are gonna reassess at least ABCs, LOC, VS, and reassess your treatment, is it helping or not. If time permits, do a full physical.

At the end of the scenario, you give a report to the proctor. When I was going to school, I just gave the report with the patient's age, gender, chief complaint, SAMPLE, pertinent positives and negatives in physical exam, and vital signs.

I started getting lazy in the middle of this, lol, but I still do hope it helped.

Edit: And quickly looking to see if I missed anything or any mistake, I noticed in my first post, I didn't mean to say "50-year-old male", I'd say something that's an estimate and obvious is one like "a male who looks like he's in his 50s", or something like that. They are probably gonna ding you at school for guessing exact age.


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## leoemt (Oct 7, 2012)

Nice post APRZ, but with all that info you forgot an important step - gain patient consent. 

To the OP: Patient Assessment is how you determine your treatment. The reason we have an "order" is so you don't forget anything. There is no rule saying you must do it in order. In fact - during my practicals we were allowed to mix things up if we wanted as long as we got all the Critical Fails. Obviously, something can't be changed though. 

Your interventions come as you need them but don't be distracted by them. What is more important: addressing the occluded airway or addressing the major bleeding wound? Life threats come first. 

SAMPLE / OPQRST is used to assist you in remembering what to ask, but is by no means the only questions you will ask. Officially for NREMT it comes at the begining of the secondary assessment, but in reality it comes when I get to it. 

Me personally, I will begin asking questions as soon as I contact the patient. I don't always ask them in order either. 

I, as well as others, could give you lots of advice but I feel it would hinder you in your class. Best of advice I can give you is study the skill sheets and practice. Don't worry about how we do it on the streets, just worry about how they want it done in class. Once you pass then you can start thinking about how you will really do it.


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## Aprz (Oct 7, 2012)

I didn't forget consent. I mentioned it at least three times and included it in my example.



> Now you make contact with the patient, you introduce yourself first. Usually your name, your level of training, and the company your work for (although that's pretty excessive in my opinion).
> 
> Now that they know who you are, your level of training, and who you work for, they can make an inform decision and consent to you helping them. This is actually kinda tricky by you really need to know if the patient is oriented or not in order for them to refuse, and in a lot of areas, age is important too. Also if they are some sort of psychiatric hold, they might not be able to make decisions for themselves. This part of the initial assessment is all merged with the next part. Also at my school, they disliked that I straight up asked for permission to help "Can I help you?" They tried to convince me not to give them that option. I really disliked that, but I expect other schools might give people trouble for that. An okayish alternative, but isn't very blunt, is "What can I help you with today?" which a lot of people in my area think is gold, and maybe it is, I am not sure.


and....



> ..... I am not blunt with these questions like I am with consent, and usually I ask for consent after I figured out what's going on and before I touch them, and I'll get them to sign the consent form right then and there letting them know that they are in charge and can accept/deny any treatment and it's up to them whether they want to be transported or not after I assess them. It may depend entirely on where you live, company policies, etc. I am gonna give you an example later on, but it's gonna be very blunt, and it's gonna be NREMT style.



and...


> _I see a 50-year-old male sitting semi-fowler's in his living room couch, clutching is chest (levine's sign) in mild distress.
> "Hello, my name is Roy, I'm an EMT with XYZ ambulance company."
> "Can I help you? What can I help you with?" <--- right there
> The patient is responsive/alert, and his chief complain is chest pain._


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## MSDeltaFlt (Oct 7, 2012)

If you notice the checkoff sheets you'll notice that they only mention "did not recognize need for high flow oxygen".  "When" is never mentioned.  So apply it when you recognize the need.


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## akflightmedic (Oct 7, 2012)

leoemt said:


> Nice post APRZ, but with all that info you forgot an important step - gain patient consent.



Reading comprehension is next semester in LEO school.


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## DesertMedic66 (Oct 7, 2012)

MSDeltaFlt said:


> If you notice the checkoff sheets you'll notice that they only mention "did not recognize need for high flow oxygen".  "When" is never mentioned.  So apply it when you recognize the need.



Per the NR sheets getting O2 on the patient is done when you are assessing the breathing on ABC. Trauma still gets high flow O2 while medical it's just says "appropriate oxygen therapy".


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## MSDeltaFlt (Oct 7, 2012)

firefite said:


> Per the NR sheets getting O2 on the patient is done when you are assessing the breathing on ABC. Trauma still gets high flow O2 while medical it's just says "appropriate oxygen therapy".



Either way, that's what I studied: the checkoff sheets.  Whatever is listed on the critical criteria: DON'T DO THAT.


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## leoemt (Oct 8, 2012)

Aprz said:


> I didn't forget consent. I mentioned it at least three times and included it in my example.
> 
> 
> and....
> ...




Last time I comment when I'm tired


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## wigwag (Oct 8, 2012)

Aprz said:


> I use the mnemonic ABC123 to remember most of the initial assessment (after sizing up the scene). ABC123 is a checklist. A, airway, 1 criteria. B, breathing, 2 criteria. C, circulation, 3 criteria.



When getting my EMT-B, for "testing purposes", I learned it as needing three things in each category, as appropriate:

Airway: (1) Open it, (2) Suck it, (3) Stick it (opa/npa)
Breathing: (1) Expose it, (2) Osculate it, (3) Palpate it  (O2 as necessary)
Circulation: (1) Pulse (is it there?), (2) Leaks (blood scan), (3) Skin (CTC)

That's what you need for an unresponsive person.  The "as appropriate" comes in when some of the steps are already satisfied by virtue of the person being conscious.

For testing purposes, I think it's best to give the O2 when assessing breathing even though that's not how it happens typically in the real world.  Otherwise, you risk forgetting it.  In many practicals, you are only verbalizing it ("At this point, I would start my Pt on 15 lpm of O2 via non-rebreather.  Does the Pt tolerate the mask?")

And don't forget, if in your protocol, it's ideal to get an SpO2 reading at room air (BEFORE O2 is applied).


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