Taking the confusion out of patient assessment and the NREMT exam
This non-linear patient assessment flowchart allows priority decision making beyond the basics of OPQRST and SAMPLE
This article originally posted at Limmer Education and is reprinted with permission.
The EMS1 Academy features the "Patient Assessment and Exam" course, a one-hour accredited course for emergency services personnel. Complete the course to learn more about patient interviewing and assessment, as well as how to calculate Glasgow Coma Scores (GCS) and perform head to toe exams.
One of the biggest issues we hear about when talking to our students and educators, after NREMT exam anxiety, is confusion about the patient assessment process for EMTs.
The EMT assessment has changed quite a bit over the years, and a brief history may help to understand why it’s such a concern today.
Brief history of the evolution of the EMT assessment
- Pre-1994 EMT-A curriculum used a primary assessment and secondary assessment approach.
- The 1994 EMT-B curriculum changed the terms and structure quite a bit. Initial assessments and focused assessments, with rapid options, became the new terms and processes. The big issue was that the EMT-B curriculum didn’t cover anything in detail if the EMT couldn’t do anything about a condition. This left gaps in both knowledge and assessment.
- Then again in 2009, education standards went back to a primary and secondary assessment concept. However, it didn’t provide the detailed steps of a curriculum. Pathophysiology and rapidly expanding treatment options made assessment even more important – but it’s taking us a while to shed the 1994 terminology and philosophy.
This brings us to 2019 where, because of the rapidly expanding toolbox, EMTs need in-depth assessment skills – yet we struggle with lingering terminology (and attitudes) of 1994.
The mantras of the old need to make way for a more mature, efficient and thought-based process. For this reason, we created the Patient Assessment Flowchart.
A few things about the new flowchart:
- The scene size-up has two distinctly different phases: the safety and resource phase and the approach to the patient phase. First, make sure the scene is safe and buttoned down. Then, look toward the patient for important clues. This method provides a seamless flow into the primary assessment.
- The primary assessment is non-linear, demonstrated by the circular graphic. What do we do first in the primary assessment? Fix the thing that is likely to kill the patient first.
- We’ve added a continuum to show that there are a wide variety of patient situations when it comes to making priority decisions. And there are multiple factors that come into play when figuring out how fast or slow you need to proceed in the rest of the assessment.
- There is a real difference between medical and trauma patients – but not as significant as it was once taught. In the trauma patient we examine multiple body systems in a hands-on exam.
- SAMPLE and OPQRST are much less prominent. This is because they’ve become a mindless crutch for students and educators. We need to return them to the place they belong – as mnemonics – for when we want to make sure we’ve covered the basics. They are not the primary driver for the history.
- So what’s the driver for history and physical exam if SAMPLE and OPQRST aren’t? Body system exams. We need to know to look for JVD and pedal edema routinely in the cardiac and respiratory patient. We must ask about orthopnea, weight gain and dyspnea on exertion. We would find none of this if we only used OPQRST and SAMPLE. Pathophysiology allows us to understand more and to know what to ask.
- In spite of the lack of the assessment terminology we are used to, this flowchart still aligns very well with the NREMT skill sheets for both medical and trauma patients.
It’s time to get rid of old, confusing mantras and make patient assessment effective, modern, thought-based and intuitive.
Please feel free to share this with your classes and agencies. We’ve also created a video overview of the patient assessment flowchart. We’d love your feedback.