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Patient Handling Tip

Everyday EMS
by Greg Friese

Patient assessment: A non-linear process

The runner hit the pavement hard. An EMT, an event medical volunteer, rushed to her side from a few feet away. The patient and the EMT were in a chaotic and dynamic scene as some runners stopped, other runners raced past, and spectators gasped, looked away, or offered to help. The EMT had no choice but to begin making a burst of simultaneous assessments and decisions.

On a skill sheet, patient assessment is presented as a linear process. First size up the scene, then complete the primary assessment followed by the secondary assessment. The steps of the primary assessment might be initiated during the size-up and continue into the secondary assessment. Because the EMT was at the runner’s side so quickly, he blocked her from being trampled by other runners and put a hand on her head to stabilize her c-spine, all while looking to see if she was breathing.

During the primary assessment, because of the urgency of the problems, provide treatments as you find the problems. If the patient doesn’t have a patent airway, then begin airway management. But, after your begin treatment or resolve a primary assessment problem, remember to complete the other components of the primary assessment.

There are three major components of the secondary assessment: patient history, vital signs, and physical exam. Start with the assessment component that is most suitable to the patient’s chief complaint. If the patient’s problem is trauma, then a detailed or head to toe physical exam maybe the best place to start. If the patient has a vague abdominal compliant, starting with the SAMPLE history will help you better understand the patient’s pain and the possible causes. For a patient with a problem that can be treated with a pharmacological intervention (like asthma or chest pain) start with getting a baseline set of vital signs.

Regardless of where you start, make sure to complete all three major components of the secondary assessment. You don’t have to complete the patient assessment as a linear process, but you do need to complete all the components. As you learn and improve your patient assessment skills, you can use a small notepad with the appropriate data fields for history, exam, and vital sign findings to ensure you collect all the information that is needed in a process that is logical for the patient and their complaint.

How do you make sure you complete all of the major components of the patient assessment? How can you help a new EMT overcome skill sheet rigidity?

About the author

Greg Friese is Editor-in-Chief of He is an educator, author, paramedic, and marathon runner. Ask questions or submit tip ideas to Greg by e-mailing him at

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Kay Vonderschmidt Kay Vonderschmidt Wednesday, November 30, 2011 4:43:26 AM really - that's all your going to write about pt assessment which is our most important skill. Take a AMLS class!
The EMS Professional The EMS Professional Saturday, December 03, 2011 8:00:51 AM Greg, you touched on an important aspect of pt assessment. That is assessing the whole process of what we are taught. The skill sheet is great for passing a class, but doesn't really reflect what we really should be doing with each patient and that is conforming and tailoring each pateint assessment to the patient in front of us. Yes key elements like airway, breathing blah blah blah have to be kept in the forefront, but we need to remember the patient called or we were called for a specifc issue. So we can indeed direct our assessment skills to the patient who called us and not for a manikin we recall testing on. Yes, Kay this is an important skill and I think way to much to discuss in its entirety in a short web article. But I think if you look at the goal of this article you will see Greg is just trying to highlight one small aspect of the patient assessment process and suggests how we should focus more on treating patients according to their complaints and presentations, rather than sticking to a rigid skill sheet no one looks at after class. I am actually doing a live podcast on this over at I plan on talking about this and other elements of how patient assessment is taught and how we should be doing it.
Lisa Carroll Lisa Carroll Saturday, December 03, 2011 8:50:38 AM Please emphasize the importance of at least 1 COMPLETE set of vital signs... I work in an ER as well as an FD... We rec'd a pt where "malaise since Mon" was chief complaint (now thurs). Medic drove, & basic in back. Basic states didn't have a bp; we asked couldn't hear one, or equip malfunction? He states couldn't hear. So after we tried 3 times, finally manually, we got 64/32. Needless to say we RAN like crazy!!! Pt was admitted, very septic, had no initial urine output until after 4 liters of fluid... Pt almost died.... I think if there had been that 1 set of vitals on scene, pt would've been brought in lights & sirens (they weren't) & the basic would not have had the call. It was an ALS call all the way around...
James Hoffman James Hoffman Saturday, December 03, 2011 3:36:10 PM Yes, vital signs for all patients. I say manual on every patient to get a baseline and sounds like this pt should have been ALS and that the pt clinical picture alone without VS should has motivated for more aggressive treatment. I dont know about txp lights and sirens, they arent getting there that much faster and teh risk is that much greater. But yes, pt vitals are key to pt assessment. I do think though that when to take them depends on pt appearance, complaint and HPI. Thanks for the comment.
Michael Green Michael Green Sunday, December 04, 2011 1:11:49 PM We need to remember that those skill sheets are actually scoring devices for passing a practical station. That is all. We should focus on learning and developing a method for assessment. Leave the skill sheet for your proctors to grade your performance.
Stephen Deegan Stephen Deegan Sunday, December 04, 2011 4:28:21 PM Initial impression before any hands-on. Big sick/little sick is the assessment which starts the flow of further assessment or immediate treatment. I've never seen this decision on a skill Sheet.
Greg Friese Greg Friese Monday, December 05, 2011 3:04:12 PM Lisa Benavidez thanks for the contribution. I am fond of saying one set of vital signs is merely interesting. Multiple sets will tell us story, like septic shock. Unable to hear blood pressure should tell us check again, as you did, try a machine like Jim suggests, or ask someone else (like a more experienced provided. Thanks all for the conversation.
Greg Friese Greg Friese Monday, December 05, 2011 3:09:46 PM Lots of other tips in these columns I have contributed to through the years,
Grant Campbell Grant Campbell Wednesday, June 06, 2012 12:06:48 AM If we all agree that a more holistic approach to patient assessment is what we really need to be doing, then why do we continue to teach EMS students the linear process? I have been mulling over new ways to teach the whole assessment process - anyone else thinking about this?