Patient Assessment: Tips from the Field for New Providers
By Brian Potter
The national standard curriculum for Emergency Medical Technician education devotes a significant amount of class time to teaching students the knowledge and skills needed to perform patient assessment. The amount of time dedicated to patient assessment clearly indicates the importance placed on the EMT having the ability to competently perform an assessment on every patient. While this is certainly justified and necessary to the development of quality EMTs, the reality is that an EMT will likely not truly become proficient at patient assessment until after getting the opportunity to perform multiple assessments on real patients in the field. While there is no substitute for this field experience, the purpose of this article is to provide a few tips from the field to aid providers in developing quality patient assessment skills.
Textbook education provides a set of guidelines for both medical and trauma patient assessments. While this material must be memorized in exact sequence for testing purposes, utilizing these guidelines and developing one’s own pattern of patient assessment over time is important to ensuring that a thorough assessment is done and critical components don’t get left out.
2. Patient assessment is an EMS skill, and serves as the foundation for all treatment decisions.
Too many times new basic life support (BLS) providers — and even seasoned EMTs frequently working with advanced life support providers (ALS) as partners — eventually get complacent with ALS providers always performing the patient assessments. When BLS providers then end up on calls as the first unit on scene or the primary care provider for the call, skills in assessment may be a little rusty. Performing a quality patient assessment is not limited to an ALS skill, but rather is an EMS skill in which all levels of providers need to be proficient. While ALS providers do obtain much more didactic and practical education in performing patient assessments, BLS providers can become very proficient at patient assessment by taking the initiative to continue learning beyond initial training and through obtaining a significant amount of field experience performing patient assessments. The patient assessment helps providers obtain the information needed to make accurate and appropriate treatments decisions for each patient, and should not be overlooked on any call.
3. Taking a thorough history is important on all calls.
It is critical not to not overlook the importance of taking a history from the patient on both medical and trauma calls. If the patient has a normal mental status, he or she can usually give the provider a pretty good idea of what is wrong before any additional physical examination is performed. If the right questions are asked, and providers listen to the answers to those questions, a great deal of information can be obtained to correlate with the findings of the physical exam. It is also important to keep in mind that, while taking a history falls at a set point in the assessment sequence according to the textbook, in real life the history is often obtained throughout the entire call as pertinent questions come to mind.
Obviously, not every patient will be conscious, alert, and oriented, and thus able to provide EMS with a history. In some cases there will not even be a family member or bystander present that is able to provide any information about the patient. In cases such as these, it is critical that EMS providers look for clues on-scene to figure out the history of the current problem. Emergent patient care should not be delayed while searching a residence for clues as to why a patient is unresponsive, but responders should be scanning the immediate surroundings and looking on and around the patient to find valuable information for the EMS providers and the ER physician.
4. Speak the patient’s language.
Learning to speak the medical language is important to be able to communicate with other healthcare providers; however, in some cases, speaking in medical terms to the patient may not lead to getting accurate information. Two examples of this are asking a patient if he/she is diabetic or if he/she takes Lasix as a medication. In some areas, especially rural ones, the provider is better served to reword those same questions to ask if the patient has "sugar" or takes a "fluid pill." If a patient denies a certain medical history, try rewording the question(s) and see if the response is any different.
5. Pay attention to your general impression of the patient, it is usually right.
When the patient assessment sequence is taught in the classroom, the general impression is included as part of the initial patient assessment. While many instructors no doubt try to stress the importance of this in overall patient care, this fact typically goes underappreciated until providers start to interact, assess, and treat real patients. The bottom line with general impressions is that sick patients usually look and act sick! When a provider arrives on scene, walks through the door, and the patient looks sick and/or the provider gets a poor "gut feeling," then following that "gut feeling" and expediting treatment and transport is usually never a bad approach.
6. Make a thorough assessment of mental status.
When using AVPU to assess a patient’s mental status, figuring out "V," "P," and "U" is the easy part. Confirming "A," on the other hand, is not always as easy as it might seem. Don’t assume that the patient’s mental status is normal just because they answer your first question correctly. Instead, talking to the patient throughout your assessment and asking good history questions as mentioned earlier can help determine if the patient is truly alert and oriented. It is well-known that subtle changes in mental status may be one of the earliest indicators of early hypoxia, so a thorough assessment and close attention to the patient’s mental status throughout the call can help a provider detect these subtle changes and provide appropriate treatment.
7. Assessing the patient’s radial pulse can tell you a lot quickly.
As previously mentioned, textbook education follows a strict sequence of patient assessment, and classroom practice often involves going through each of those steps in order. In the real world of assessing patients, many steps of the assessment may be done simultaneously, and one step that can quickly provide a lot of information is assessment of the patient’s radial pulse. Reaching down and checking the patient’s radial pulse while conducting the initial interview with the patient can provide a quick estimate as to the location of the patient’s blood pressure. The presence of a strong radial pulse indicates that the patient’s systolic blood pressure is at least 90-100 mmHg or better, while the complete absence of a radial pulse indicates that systolic blood pressure is less than 90 mm Hg.
A rapid radial pulse may indicate the presence of some form of shock or anxiety, while a very slow radial pulse rate may indicate some sort of cardiac pathology, such as an electrical abnormality. Assessing the radial pulse for regularity is also important, as an irregular heart rate may also indicate some sort of arrhythmia with the heart. Certainly the preceding is not an all-inclusive list of what the assessment findings of the radial pulse may indicate, but they do illustrate some of the information quickly obtained from such an assessment that can then be correlated with the patient’s history and remainder of the assessment findings.
8. Learn to adapt and overcome.
As with just about everything in the world of EMS, Murphy's Law comes into play more often than not. If something can go wrong on an ambulance call — especially the bad ones — chances are it will probably go wrong. This statement does not exclude patient assessment, so providers need to be prepared to follow the age old adage, "adapt and overcome." Not everything will happen as the textbook says it should, so keeping this motto in mind and thinking critically in every situation will help providers perform quality patient assessments and hopefully provide quality patient care.
Patient assessment is a critical skill for EMS providers as it provides the information from which treatment decisions are based.
Classroom education in EMS devotes a great deal of time to teaching assessment skills to new EMS providers, and gaining field experience after certification is no doubt crucial to an EMS provider achieving proficiency at performing patient assessments. This article has provided a few tips from the field that new EMS providers can try to implement into their own patient assessments while beginning to obtain that field experience and hone their skills. Ultimately the goal for all providers is to provide the highest level of emergency care to the patient, and the ability to perform a quality patient assessment is a huge step toward achieving that goal!
Brian Potter, MS, ATC, EMT-B is a member of the Upshur County Emergency Squad and a West Virginia Emergency Medical Services Instructor, and serves as Adjunct Instructor in Exercise Science at West Virginia Wesleyan College. You can contact him at firstname.lastname@example.org.