# Patient Assessment



## AShaddeau (Mar 21, 2013)

I'm getting confused on when to use the different assessments. I've been taking practice tests and there have been a few questions where it asks me what assessment I would use first. Initial assessment, Trauma assessment, secondary assessment... :unsure:


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## Veneficus (Mar 21, 2013)

This is a common question.

As a test taking tip, never choose "secondary" as the first assessment you would do.


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## AShaddeau (Mar 21, 2013)

I'm familiar with the assessments; as I should be, I'm just confused as to when I use certain ones at certain times.


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## NomadicMedic (Mar 21, 2013)

The initial assessment is to identify and correct immediate life threats. The FIRST thing you do. For example, if they aren't breathing, identify it and fix it. 

The trauma assessment is to identify traumatic injuries not identified in the initial assessment. Expose, examine and palpate. 

The secondary assessment is performed after immediate life threats have been identified and corrected. Also known as the "let's see if we can find anything else wrong" assessment. Usually done while en route. 

Does that help?


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## AShaddeau (Mar 21, 2013)

So, no matter what I perform the initial assessment? 
It does help, Thank you! 
I think it will be easier once I'm doing ride alongs and seeing/doing it first hand. I appreciate all the help.


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## Medic Tim (Mar 21, 2013)

AShaddeau said:


> So, no matter what I perform the initial assessment?
> It does help, Thank you!
> I think it will be easier once I'm doing ride alongs and seeing/doing it first hand. I appreciate all the help.



yes, every pt gets an initial assessment

practice on pets, family, friends, lamps.. anything. The more you go through it the easier it will become.


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## donkeypuncher (Apr 3, 2013)

AShaddeau said:


> So, no matter what I perform the initial assessment?
> It does help, Thank you!
> I think it will be easier once I'm doing ride alongs and seeing/doing it first hand. I appreciate all the help.



need to learn the script first...On ride alongs you may see bad habits or you ma think are not doing something, because they have already ruled out stuff in their head


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## mycrofft (Apr 3, 2013)

GO to your text, assiduously search (at least three Mt Dews) for the answer they want, then learn it. If not found, talk to teacher or most attractive classmate.


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## Akulahawk (Apr 3, 2013)

donkeypuncher said:


> need to learn the script first...On ride alongs you may see bad habits or you ma think are not doing something, because they have already ruled out stuff in their head


True! People that are very good this may appear to skip certain portions of their exams because they've already looked for it and moved on before you're able to keep up, or they're already onto doing a focused assessment because they've already done an initial assessment and are already beginning to focus in on what the problem may be. I generally do a quick "obvious" sick/not-sick assessment every time I make patient contact. From there I move into doing that initial assessment and focus in from there to what the problem seems to be. I've been at this a while, so it might look like I just walked in and started talking to the patient while I get (or have someone get) vital signs... and appear to ignore other areas. Trust me, I haven't. I'm refining that assessment as I go and will add other areas of the assessment as I need to. 

Unfortunately, the side effect is that it appears that I'm either doing things out of sequence for how you learned them or that I'm "lazy" or I'm just not doing things right, simply because I'm doing things differently. When I'm training someone, I'll generally take time after the call, or during the call if time permits, to explain what I do, why, and I'll do things the more "textbook" way if the opportunity presents itself.

For you, the new EMT learner, you need to learn the textbook "script" so that you don't miss anything and so that later when you're starting to do more focused assessments, you can just pull from that script the things you need.


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## Wheel (Apr 3, 2013)

mycrofft said:


> ...talk to...most attractive classmate.



Good advice even if you don't need help.


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## Brandon O (Apr 3, 2013)

If you can find an AMLS course, I'd take it; they do a very good job of operationalizing this subtle process of cascading assessment. You can't really execute it until you have the knowledge to know what you're looking for, but at least you can learn the method.

Edit: on a more mundane basis, 90% of your initial general impression, no matter how much people wave their hands about it, is derived through:

1. The patient's level of distress, behavior, and mental status
2. The patient's breathing
3. The patient's skin

In other contexts, they call this the Pediatric Assessment Triangle (PAT), but it really applies to everyone. If you walk in, look at the patient, engage them in conversation, and perhaps feel a peripheral pulse, you know a great deal about their neurological, respiratory, and hemodynamic status.


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## Akulahawk (Apr 4, 2013)

Brandon Oto said:


> If you can find an AMLS course, I'd take it; they do a very good job of operationalizing this subtle process of cascading assessment. You can't really execute it until you have the knowledge to know what you're looking for, but at least you can learn the method.
> 
> Edit: on a more mundane basis, 90% of your initial general impression, no matter how much people wave their hands about it, is derived through:
> 
> ...


I use the PAT concepts all the time on people. Personally, I walk in, see how the patient reacts to change in the environment (me coming in), introduce myself, and offer a handshake... all while watching how the patient is breathing. Like you said: Neuro, Respiratory, Hemodynamic status in a very crude way. 

While I've not taken an AMLS course formally, I've read the book more than a few times and done some self-learning along the way using that as a guide. Eventually I'll take it formally and learn some more!


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## bigbaldguy (Apr 4, 2013)

Initial= Holy crap how'd you get a golf ball stuck in your throat, never mind lets just get it out.

Trauma= Hey where's all this blood coming from? Crap did anyone remember to pick up the guys fingers?

Secondary= Wow we're still 10 minutes from hospital. Wonder if this guy has bunions.


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## Ace 227 (Apr 5, 2013)

bigbaldguy said:


> Initial= Holy crap how'd you get a golf ball stuck in your throat, never mind lets just get it out.
> 
> Trauma= Hey where's all this blood coming from? Crap did anyone remember to pick up the guys fingers?
> 
> Secondary= Wow we're still 10 minutes from hospital. Wonder if this guy has bunions.



hahaha, I literally laughed out loud. Thanks for that


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## Clare (Apr 5, 2013)

The primary survey is a quick, initial examination to see the state of ABCD and if there are any life threatening problems.  For example, do they have an airay, are they breathing, do they have a pulse, what is their level of consciousness and is there any massive haemmorhage, limbs that are missing, impaled objects in non anatomical places?

The secondary survey is a more detailed, thorough examination; for example it establishes what the respiratory pattern and rate is, what the pulse quality and rate is, GCS, and looks for injuries.

Then you have the system specific examinations for example cardiovascular, respiratory, GI/GU etc.  

Personally I think the textbook secondary survey has more of a role in somebody who has been traumatically injured than in somebody with a medical problem and that the secondary survey and system specific examinations sort of blend into one another, at least in somebody who has a medical problem.

Like most things, there is no one right or wrong answer and clinical judgement is required.


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## joshrunkle35 (Apr 5, 2013)

And general impression is what you see as you're walking/driving up. "My general impression is that there is a man found face down lying in the roadway from an apparent MVA." Or similar.


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## Clare (Apr 5, 2013)

I guess you could call general impression your first take of the patient, i.e. how sick (or how injured) are they, what are their major problems and how time critical is their problem?

For example you could say that a general impression of the person who is unconscious having been ejected from a road crash is going to be very time critically injured, or dead.  

Impression (written as I) or "imp") can also be used to describe somebodies impression of the patients problems.  For example Imp (1) DKA (2) Hyperglycaemia (3) Dehydration (4) Infection ? cause


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## MrJones (Apr 5, 2013)

Oops - wrong thread.

Never mind.


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## VirginiaEMT (Apr 7, 2013)

AShaddeau said:


> I'm getting confused on when to use the different assessments. I've been taking practice tests and there have been a few questions where it asks me what assessment I would use first. Initial assessment, Trauma assessment, secondary assessment... :unsure:



On the skill sheets, the beginning is the same regardless if it is trauma or medical. 

THE FOLLOWING STEPS ARE THE SAME:

THE BEGINNING
Scene safety/BSI
MOI/NOI
# of patients
additional resources needed?
C-Spine

Then I remembered GMABCP (I actually remembered these letters)

THE MIDDLE
G-general impression
M- Mental status
A- Airway
B- Breathing
C- Circulation
P- Priority of the patient

The middle part is a little different


The end- Always do your secondary assessment, reassess vitals, and address any secondary wounds en route and you will be golden.


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## hogdweeb (Apr 8, 2013)

VirginiaEMT said:


> On the skill sheets, the beginning is the same regardless if it is trauma or medical.
> 
> THE FOLLOWING STEPS ARE THE SAME:
> 
> ...


depending on your service, and if you have an I or P on board, contact ALS if the MOI or chief complaint could be ALS, such as cardiac or MVA with PI.


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## ipkes (May 2, 2013)

VirginiaEMT said:


> On the skill sheets, the beginning is the same regardless if it is trauma or medical.
> 
> THE FOLLOWING STEPS ARE THE SAME:
> 
> ...




Thanks for the new mnemonic, ill definatly use this


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## kaisardog (May 6, 2013)

well I  can  only  tell  you  what  worked  for  me  in  passing  all  the  7  NREMT skill  stations  including   the  trauma  and  med  practicals  last  week:
1.  Get  the  NREMT  skill  sheets  for  trauma  and  medical. (and  CPR/AED, BVM, NRB, backboard,,, etc .) 
2. Memorize  the  exact steps  they  tell  you  to   do.  Yes,  Every  step.  Yes,  in  that  exact  order. 
3. get a  dog, a  spouse  or some  couch  pillows. without  looking at  the  skill  sheet,   start  a  timer  and   run  thru  the  whole  skill  sheet  on  it/him/them  and talk  out  loud  into  your   ipod  or  tape  recorder."I  am arriving  on  scene  w wearing  proper  BSI  of  gloves  with  goggle and  2  masks , 1 a  HEPA,   in  my  pocket.  i  ask  is  the  scene  safe  and X  replies  that  it  is. I  ask  how  many  patients , reply  1. i  call  ALS  stating   general  impression repeating  the  dispatch  info-,   MVA   with  one eject middleage  male  in pool of  blood motionless  and  prone on  the  median  (or  any  of  the 15 other  'category 1 ' trauma priorities  on  my  state  transport  protocols.)  .. obvious  head  trauma  and  possible  c spine  injury  .   alert  for possible helo evac. ..I  now  ask  EMT partner  to  hold  manual  c  spine while  i  assess AVPU (find pt reponsive to  pain  only) and I assess  life  threats  Airway- airway patent  and  clear  no  fluids,  breathing rapid  and  shallow,  carotid pulse slow   weak ..distal  pulse  present...etc. thru  the  whole  skill  sheet.  
      then play  back  what  you  just  recorded    as  all  your  assessments.   and  compare  what  you  said  to  the skill  sheet. you  will  flunk  yourself  20  times  before  you  run  thru  the  whole  skill  sheet  completely 'right' and  in proper  order. .( take  a  med  or  trauma  hypo  from  your  AAOS  or Limmer  book  and  use  that  as  your  problem.) 

i  found  my  most  common  mistakes  were  not calling  ALS   ,  not  upgrading  transport  to  rapid  or helo,   and  forgetting  to  check  RR, breathing ,  pulse  and  PMS  both     before  and  after  all interventions. i(ncluding  epi,  albuterol, NG, ASA,  charcoal, glucose, o2,   blankets,  backboards, KEDs , putting splints,  sling/swathes  on, putting  bandages  or  c - collars  on...) 

so  make  your  own  mnemonics--mine  was  'don't be  snagged':  BSNAAG for:  Bsi /Scene safe, Als, Assist (/fire-vertical rescue  electric  co.  etc)  and  Gen  impression --  then  move  to  CA-ABC-CAOT: C (hold  manual  C - spstabilization)  -AVPU-  Air Breathe Circ -C Collar  put on - Als upgrade (intercept  or  helo?), o2 (they  always  need  o  2  ) and  T (where  to  transport: burn unit,  neuro, decompression  chamber? trauma  1,  general  hospital ?) 
then  you  can  DCAPTBL  and PMS them  thru  the 90  sec  rapid  trauma,  then backboard them  while SAMPLE  and  OPQRST  them.   ask  the  examiner  each  and  every  question  head  to  toe in  rapid  trauma:Am  I  seeing  blood  or  teeth  blocking  airway ,skin  normal  color  ?  am i seeing  normal cap  reflex, lost  distal pulse,   raccoon eyes  battle  signs frothy blood , JVDs, SQt edema, rales  ronchi wheezes punctured  chest  walls,   rigid  abdomens, cullen  signs ,  non PEARRLs,   CSF  from  ears  or  nose,    the  whole  litany  of  every awful  thing you  can  think  of  from  head  to  toe. then  finish  the  alphabet  soups , tell  examiner  helo  is  on  scene  and state you'll treat  the  ever present  distracting  injury (like ,   splint  the closed  broken  ankle etc.) during  transport, )  stating  'i  am  taking  vitals  during  transport  and I  am  reassessing ABCs  and  all  interventions  including  PMS ..every  (5  or  15)  minutes  then  state  ALS  or  HELO  is  here  we  are  loading ,  i  am  radioing  in  my  field  impression  :  male  30  yo /glasgow  coma  scale  5 head  injury / o 2 intervention / neuro  unit  at  hospital X  has  been  alerted/  helo transport  ETA  __  minutes... 

remember  that  the  examiner  is  writing  on  his/her  paper as  you  do  things.  s/he  has  to  hear  you  do  something  to  award  the  point.  if  you  skip  out  of  order  they  will  have  a  more  difficult  time  giving  you  the  check  off  for  doing  that  particular  skill because  they  have  to  jump  ahead  or  back  on  the  skill  sheets. memorize  your  chosen  alphabet  soups,   do  everything  in  NREMT  order,  make  their  examiner-lives  simple.  you   have  now  finished   the  whole  trauma station  within the  ten  minutes  allowed  for  NREMT   Trauma   Station skills ..  and  gotten  42  of  42  possible  points  (29  required  to  pass  with  no  critical  fails  of forgetting  an ABC  or  forgetting a  PMS  or  the  other  long  list  of  things...) 

google  NREMT  skill  sheets .

good  luck.


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