# need some help with trauma assessment!



## Longo118 (Jun 1, 2010)

Hello all, hoping i can finally get a straight answer from somebody!

Im going through my NYS EMT-B class, I have state practicals next week and needed some help with trauma assessment. 

My question is, When EXACTLY do you take care of life threatening injuries? and if they are NOT life threatening, when do you take care of them?

How i was taught the assessment goes like this (briefly):

Scene safety
BSI
MOI
C-spine

General impression
AVPU
chief complaint

Airway - suction? OPA / NPA
Breathing - Bare chest, listen to apexs, check bilateral chest expansion, feel for holes, decrepitations etc
Circulation - pulse r+q, skin ctc, gross bleeding
Decide - priority or not

rapid assessment (DECAP-BTLS) collar them check apex again and check PMS

board them up, load them in rig

Vitals, SAMPLE

Detailed assessment

On going assessment

Any feedback on this thread is greatly appreciated!


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## jjesusfreak01 (Jun 1, 2010)

I was (am being) taught that if the life threatening injury is blood loss, you pretty much hit it either right away or during the C on your ABCs. Obviously if the life threatening injury is airway or breathing related, the same applies. Non immediately life threatening injuries, such as a slightly bleeding stab wound or a flail chest should be handled during a rapid trauma assessment, as you get to that part of the body in your assessment. Any other injuries, such as cuts, burns, etc can be handled in the detailed assessment on the way to the hospital. Also note that some patients may be bad enough that they go right into the ambulance after plugging the big holes and such.


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## Longo118 (Jun 1, 2010)

I been told 2 different ways, and the way you just stated does seem to make the most sense, but i just wanted to make sure its right. Because in NY its critical to pass the practical for when to take care of life threatening injuries and secondary injuries. 

Thanks jesusfreak


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## adamjh3 (Jun 1, 2010)

This might not help you, but take it for what it's worth. I broke my assessments into five blocks, and made (or used pre-existing) mnemonics for each one. 

Block One: PENMAN

P PPE (Personal Protective Equipment, this is where you don your BSI)
E Environtment - this is scene safety
N Number of Patients
M Mechanism of Injury or Nature of Illness
A Additional Resources - Are you going to need any help with this? ALS? An engine?
N Need for C-spine

Block Two: GAP

G General Impression
A AVPU
P Problem - The patient's Chief Complaint, this is where you check for apparent life threats such as major uncontrolled bleeding, etc.

Block Three: AB+CT

A Airway
B Breathing - Put every single patient on high flow O2 right here for the sake of the national registry
C Circulation 
T Transport decision - decide if you're going to stay and play or load and go.

Block Four: ABS

A Assessment - decide if you're going to perform a rapid or a focused assessment. I usually only do a rapid up front if the patient is altered LOC, unconcious, or they have significant distracting injury such as a femur Fx or other "serious" trauma. 
B Baseline Vitals
S SAMPLE history

Block Five: Detailed physical exam. No mnemonic for this one, but it's pretty self explanetory, you assess the patient from head to toe, looking for any DCAP-BTLS, other injuries, or signs of medical Hx (CABG scars, pacemakers, etc). If there is bleeding from the ears or nose, do the "halo test" to check for CSF. 
Basically just run down and hit Head, Neck, Chest, Abdomen and Pelvis (make sure you verbalize the genitals and perinium), the extremities and the patient's posterior.


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## Dominion (Jun 1, 2010)

IF you follow the NREMT sheets and your teachers instructions it should be as follows:

Just before assessing your ABC's the sheet asks you to assess for chief complaint/aparent life threats.  You would verbalize this as:

"Do I see any immediate threats to life?"
"No"
Continue Skill sheet OR
"Yes, your patient has a wound to his neck that has bright red blooding spurting out."

At which time you will need to manage that life threating wound.  

Additionally you will need to assess a 'life threatening bleed' during the C phase of ABC's.  

At any time during your pt exam if your proctor states your patient has a life threatening injury you are to stop your skill sheet and manage that injury until told otherwise.  While I've never seen/heard of this happening in actual boards, my EMT and paramedic instructor would VERY often throw two or three skills together to try and trip you up


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## Longo118 (Jun 1, 2010)

Adamjh3 Thats actually a great way to remember the entire assessment. I wish i learned it this way. As long as you remember each letter of the acronym its honestly fail proof. Kudos for coming up with that and thanks!

Dominion a bunch of mu buddies ended up printing out the exact practical exam check off sheets in class the other night, (They are on the NY state EMT-b registry website) and the instructors over heard the kids in the class talking about them and they gave us this whole rant about how if we ever get caught looking at those sheets before we get tested we can automatically fail. So what did i do? i went home and found it online and printed it out to study  But its a little more confusing than the national registry sheet haha


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## MonkeySquasher (Jun 1, 2010)

First I'll start with...  I respect the opinions of both of the previous posters.  And yes, they are both correct.  In fact, take two elements of adamjh3's post  "Number of Patients" and "Additional Resources" and add them into your Scene Sizeup if you want to slightly impress your proctor.  Just be sure you don't screw up later and can back up that initial impression.  

But NYS is a whole different beast in how it does practical exams, because you have to do certain things in a certain order or you fail.. -_-  Since taking my original Basic, I've assisted in Practicals every year since, so I can give you a little heads up into it.

First, are you taking it at a NYS academy, or a local college/fire hall?  If it's the former, you have to be VERY on top of things.  If it's the latter, you tend to have a little more leeway, but should still be on top of it, as you never know when your proctor will be a stickler and when they'll let some things slide.

To answer your question...
Technically, the correction of life-threatening conditions happens immediately upon finding them during the Initial Assessment.  If you're doing ABCs and you find the airway is open but they aren't breathing, you stop at "B" and bag them.

Look here to follow me:  http://www.health.state.ny.us/nysdoh/ems/pdf/emtpse08-06.pdf

You start with your Scene Sizeup.  Annouce you're wearing BSI, ask if the scene is safe.  It always will be.  (lol)  Assure that it is only one patient (always is), ask for your MOI.  They'll explain what happened.  If necessary, state the need for C-Spine and ask if you're on a Medic Rig.  They'll say No, and you call for ALS if necessary.  If you say "Call for a helicopter and set up a landing zone" they'll normally laugh at you.

Next, ASK THEM what your General Impression is.  They should tell you what you're looking at...  Ex:  A male flew off his motorcycle and is laying in a field on his back with his one leg at a weird angle and blood from somewhere.  All you do is repeat it, add whether you think it's good or bad, and what you're thinking of doing so far.

Now talk to your patient.  If they answer, ask what hurts/what happened/etc.  If they don't answer, try pain.  Usually they answer to pain at the least.

Now ABCs.  "Is my patient breathing?"  (Usually yes)  "Is my patient breathing adequately?"  (Usually yes)  "Is there any notable airway obstruction, or the chance of a future obstruction?"  (Usually no)  "I place my patient on O2 15LPM via NRB"  (I dont agree with it, but per the state, you have to say it.  -_-)

"Does my patient have a pulse?"  (Always)  "Do I see any major or obvious bleeding?"  (If so, have your partner plug it)  "How does my patient's skin color and temperature look?"  (*THIS IS IMPORTANT.*  It is a critical, and what fails people the most, I find.)

Then you give your transport decision.  Usually, if it's anything to do with ABC compromise, you transport immediately and do a rapid trauma assessment as you place them on a longboard.  If it's something localized and you haven't had to do a lot yet, you can do a focused assessment.  However, I've never seen a student say "load and go, do the rest in the rig" and be faulted for it by a proctor.

If it's a major trauma, VERBALIZE making them naked.  ()   Do head/face/neck.  Chest..  Look, listen, poke at it.  Rock the pelvis, feel down the legs, check PMS.  Go back to the uppers, check the arms, PMS.  This has just checked your PMS pre-boarding, and you're back in position to take the trunk.  Roll, and CHECK THE BACK before you place on the board.  Be sure to verbalize it too, nice and loud.  It's the most missed part of assessment, I find.  Now, clip them in, make them squeeze your hands, tell them to wiggle their feet, and you're done.  Verbalize a SAMPLE and OPQRST during transport, and you won't even need to remember the questions.    As for DCAPBTLS, LEARN IT.  If you say it, a good proctor will call you on it and ask what it means.  Don't embarrass yourself.  haha

If you get lost, don't panic.  Just start over at ABCs, and go from there.  If you're still completely stumped or overwhelmed, make sure you get through your ABCs, say you're transporting immediately, give O2, and you've atleast covered your criticals.

The station gives you 15 minutes.  Entire time for Scene Sizeup, if done properly, is less than 2 minutes.  ABCs, unless you really have a screwed up patient, are another 2-3 minutes, and you can usually do the rest in 5 minutes.  I find a well-prepared student can do the whole station (by memory) in about 7-10 minutes.


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## mcdonl (Jun 1, 2010)

Dominion said:


> IF you follow the NREMT sheets and your teachers instructions it should be as follows:
> 
> Just before assessing your ABC's the sheet asks you to assess for chief complaint/aparent life threats.  You would verbalize this as:
> 
> ...



I am done with training for the summer!! (WOO HOO!!) so I am asking this out of respect and to clear up what I learned...

In the above scenario... what if the patient also had an obstructed airway, but you never checked for it because you jumped right to "C"? 

Again, I mean no disrespect but we had a practicals class where the same scenario you just laid out took place (Except the bleed was from the upper leg) and the EMT student jumped right to the bleeding while the "patient" did not have an airway. In real life, this may be the best thing to do but in the "tom foolery" world of EMS would this be considered a "trick"?


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## Melclin (Jun 1, 2010)

This mnemonic obsessed culture of prehospital practice really bothers me. I understand that this thread was about passing an exam, but this whole dot point approach to being an ambo really bothers me. 

Honestly, if you have to sit with a trauma pt and ask yourself, "Okay..DCAP-BTLS...does the pt have any depressions...No?...now...um...Contusions?...". Those mnemonics are all good and well for a first year, but to actually be practicing with that kind of an understanding? What injuries you should be focusing on should flow from your understanding of how life threatening or potentially life threatening those injuries are.. not from a mnemonic that throws you one line answers for some abstract exam.


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## Dominion (Jun 1, 2010)

Melclin said:


> This mnemonic obsessed culture of prehospital practice really bothers me. I understand that this thread was about passing an exam, but this whole dot point approach to being an ambo really bothers me.
> 
> Honestly, if you have to sit with a trauma pt and ask yourself, "Okay..DCAP-BTLS...does the pt have any depressions...No?...now...um...Contusions?...". Those mnemonics are all good and well for a first year, but to actually be practicing with that kind of an understanding? What injuries you should be focusing on should flow from your understanding of how life threatening or potentially life threatening those injuries are.. not from a mnemonic that throws you one line answers for some abstract exam.



I don't speak for others just myself.  In my case I find them helpful for remembering things like practical exams and keeping a general tally on some things.  For example AHA algorithms are pretty straightforward to remember however if you don't know how to apply those algorithms to an ever evolving situation, then they're useless.  

As for trauma/medical sheets, I feel that's somewhat of an error on the education systems part.  As EMT Basics, Intermediates, and Paramedics we are required to memorize these skill sheets for a practical board.  Where missing several of the minor steps can result in failure of the skill station.  In this regard making mnemonics to help you remember those sheets can be helpful.  I know when I'm infront of people giving me scenarios I tend to freeze on what to do next just because the sheets ARE so vastly different than practicing in the field.


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## Shishkabob (Jun 1, 2010)

If it's life threatening, you take care of it when you see it.

If it's not life threatening, you do it in the rig on the way to the hospital or not at all as you have more pressing matters.  


Don't worry about splinting an arm if they have a sucking chest wound.


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## adamjh3 (Jun 1, 2010)

Melclin said:


> This mnemonic obsessed culture of prehospital practice really bothers me. I understand that this thread was about passing an exam, but this whole dot point approach to being an ambo really bothers me.
> 
> Honestly, if you have to sit with a trauma pt and ask yourself, "Okay..DCAP-BTLS...does the pt have any depressions...No?...now...um...Contusions?...". Those mnemonics are all good and well for a first year, but to actually be practicing with that kind of an understanding? What injuries you should be focusing on should flow from your understanding of how life threatening or potentially life threatening those injuries are.. not from a mnemonic that throws you one line answers for some abstract exam.



I agree with you. I don't hop out of the ambulance, approach my patient and go "Okay, PENMAN, GAP, ABCT, ABS..." This was just how I learned the sheet to pass the exam. I'm not sure how I feel about the system using these "Assessment sheets," on one hand, I've never used it in the field, I treat the patient, not the paper, and the majority of what's on "the sheet" just happens without thinking about it. On the other hand, I can see it as providing something to fall back on if you freeze in the field. That is certainly no substitute for a proper education, but I can see it being utilized as a supplementary tool.


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## MonkeySquasher (Jun 1, 2010)

Dominion said:


> As for trauma/medical sheets, I feel that's somewhat of an error on the education systems part.



^ This.   They make you do it for the exam in a way that is only loosely tied to the field.

Do I do assessments that hit all of these points?  Yeah.  Do i do it in this order?  Occasionally.  Usually more for trauma than medical.  Do I do it in the exact order or use the mnemonics like that?  No.  It basically becomes doing it one way to pass, and then learning a different way to apply it after.


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## Longo118 (Jun 1, 2010)

MonkeySquasher said:


> First I'll start with...  I respect the opinions of both of the previous posters.  And yes, they are both correct.  In fact, take two elements of adamjh3's post  "Number of Patients" and "Additional Resources" and add them into your Scene Sizeup if you want to slightly impress your proctor.  Just be sure you don't screw up later and can back up that initial impression.
> 
> But NYS is a whole different beast in how it does practical exams, because you have to do certain things in a certain order or you fail.. -_-  Since taking my original Basic, I've assisted in Practicals every year since, so I can give you a little heads up into it.
> 
> ...



Thank you monkey squasher, I came to this forum with hopes i could find someone else from NYS who already took it (and possibly even helped with practicals) so i can learn what to remember and what was critical and most forgotten. Thank you again this was a huge help! 

especially because i heard by my instructor NYS is easily one of the hardest EMT-b practicals in the country.

Thank you and thanks everyone else who posted you all were a great help!


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## Melclin (Jun 1, 2010)

Yeah I wasn't having a go at the OP or anyone for giving him answers, like I said, I get that its just about passing an exam. We have a similar issue here although far less extensive, in that people who approach scenario exams at uni like real jobs will almost undoubtedly fail, despite the quite open acknowledgment on the part of the uni that it was realistically handled well. 

Just venting my frustration at the magnified version of that issue that you guys have over there.


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## dudemanguy (Jun 1, 2010)

I dont know if this would differ from NY state's practical exam. But the national registry skill sheet I studied with had "determines chief complaint/apparent life threats" together as one step. So on your list it would be after AVPU and before airway. This is the way I did it during my actual exam and I got 40 out of 40 points on trauma so it worked for me. 

It's not a critical fail if you dont verbalize it in that exact order, or even at all, but obviously if you dont discover and address all life threats as you go through the scenario, that is a critical fail. 
I would think you would be able to get the actual trauma assessment/management skill sheet off the internet at whatever state government website deals with EMS.


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## dudemanguy (Jun 1, 2010)

I dont know if this would differ from NY state's practical exam. But the national registry skill sheet I studied with had "determines chief complaint/apparent life threats" together as one step. So on your list it would be after AVPU and before airway. This is the way I did it during my actual exam and I got 40 out of 40 points on trauma so it worked for me. 

It's not a critical fail if you dont verbalize it in that exact order, or even at all, but obviously if you dont discover and address all life threats as you go through the scenario, that is a critical fail. 
I would think you would be able to get the actual trauma assessment/management skill sheet off the internet at whatever state government website deals with EMS.


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